Provider Demographics
NPI:1194372755
Name:JACKSON, PATSY
Entity Type:Individual
Prefix:
First Name:PATSY
Middle Name:
Last Name:JACKSON
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 1:321 MARGIE HARRELL ST
Mailing Address - Street 2:
Mailing Address - City:DIBOLL
Mailing Address - State:TX
Mailing Address - Zip Code:75941-2300
Mailing Address - Country:US
Mailing Address - Phone:936-829-5762
Mailing Address - Fax:
Practice Address - Street 1:321 MARGIE HARRELL ST
Practice Address - Street 2:
Practice Address - City:DIBOLL
Practice Address - State:TX
Practice Address - Zip Code:75941-2300
Practice Address - Country:US
Practice Address - Phone:936-829-5762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider