Provider Demographics
NPI:1134645674
Name:JACKSON, STACEY (FNP-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 HOSPITAL PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-5913
Mailing Address - Country:US
Mailing Address - Phone:817-848-2880
Mailing Address - Fax:817-848-2890
Practice Address - Street 1:1604 HOSPITAL PKWY STE 100
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-5913
Practice Address - Country:US
Practice Address - Phone:817-848-2880
Practice Address - Fax:817-848-2890
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134528363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily