Provider Demographics
NPI:1134479686
Name:JACKSON, GINECE JASMINE (MD)
Entity Type:Individual
Prefix:DR
First Name:GINECE
Middle Name:JASMINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 WOODSTEAD CT STE 208
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-1480
Mailing Address - Country:US
Mailing Address - Phone:877-749-7428
Mailing Address - Fax:512-628-3314
Practice Address - Street 1:2000 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2443
Practice Address - Country:US
Practice Address - Phone:877-749-7428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ54090208100000X
NJ00000000000000000000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation