Provider Demographics
NPI:1093062515
Name:MACKERT, JESSICA LEE (RN, NP-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:MACKERT
Suffix:
Gender:F
Credentials:RN, NP-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:LUKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, NP-C
Mailing Address - Street 1:1010 W 40TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-4010
Mailing Address - Country:US
Mailing Address - Phone:512-459-8753
Mailing Address - Fax:512-483-6807
Practice Address - Street 1:15803 WINDERMERE DR
Practice Address - Street 2:SUITE 103
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-2402
Practice Address - Country:US
Practice Address - Phone:512-989-2680
Practice Address - Fax:512-406-7339
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX735503363LF0000X
TXAP122124363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX339037902Medicaid
TX339037903Medicaid
TX339037902Medicaid
TX468915YKXVMedicare PIN