Provider Demographics
NPI:1215562848
Name:THACKER, CASSIE JEAN
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:JEAN
Last Name:THACKER
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 1:5131 E US HIGHWAY 84
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-1451
Mailing Address - Country:US
Mailing Address - Phone:903-284-7741
Mailing Address - Fax:
Practice Address - Street 1:805 N DICKINSON DR
Practice Address - Street 2:
Practice Address - City:RUSK
Practice Address - State:TX
Practice Address - Zip Code:75785-1006
Practice Address - Country:US
Practice Address - Phone:903-284-7741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1071339363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily