Provider Demographics
NPI:1215592225
Name:JACKSON-GREEN, MIRANDA C
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:C
Last Name:JACKSON-GREEN
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 1:18250 ETON RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-2297
Mailing Address - Country:US
Mailing Address - Phone:346-244-9705
Mailing Address - Fax:
Practice Address - Street 1:16318 ESPINOSA DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-2812
Practice Address - Country:US
Practice Address - Phone:346-779-9965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246RM2200X
LACLP.204021-PHL246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory