Provider Demographics
NPI:1073735445
Name:JACKSON, KATRINA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 POTOMAC DR
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-4847
Mailing Address - Country:US
Mailing Address - Phone:281-557-7640
Mailing Address - Fax:
Practice Address - Street 1:2911 S SHORE BLVD STE 190
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-3919
Practice Address - Country:US
Practice Address - Phone:281-538-8188
Practice Address - Fax:281-538-8189
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA030501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C8696Medicare ID - Type Unspecified