Provider Demographics
NPI:1093295719
Name:JACKSON-CENALES, OTEKA
Entity Type:Individual
Prefix:
First Name:OTEKA
Middle Name:
Last Name:JACKSON-CENALES
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 1:505 E TRAVIS ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670-4258
Mailing Address - Country:US
Mailing Address - Phone:318-393-5407
Mailing Address - Fax:
Practice Address - Street 1:505 E TRAVIS ST STE 112
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-4280
Practice Address - Country:US
Practice Address - Phone:318-393-5407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX747761363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner