Provider Demographics
NPI:1083114888
Name:JACKSON, ROSIE M
Entity Type:Individual
Prefix:
First Name:ROSIE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 SILVER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-4577
Mailing Address - Country:US
Mailing Address - Phone:972-296-0886
Mailing Address - Fax:
Practice Address - Street 1:419 SILVER CREEK DR
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-4577
Practice Address - Country:US
Practice Address - Phone:972-296-0886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX805795163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse