Provider Demographics
NPI:1154821668
Name:JACKSON, MARITA CECILIA (LVN)
Entity Type:Individual
Prefix:
First Name:MARITA
Middle Name:CECILIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 S JUPITER RD APT 924
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-3074
Mailing Address - Country:US
Mailing Address - Phone:619-416-5775
Mailing Address - Fax:
Practice Address - Street 1:327 S JUPITER RD APT 924
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-3074
Practice Address - Country:US
Practice Address - Phone:619-416-5775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA185680164X00000X
TX338145164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse