Provider Demographics
NPI:1558595371
Name:JACKSON, MARY KATHLEEN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHLEEN
Other - Last Name:CROIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23802 HIGHWAY 59 N
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-1510
Mailing Address - Country:US
Mailing Address - Phone:281-312-5465
Mailing Address - Fax:281-312-5440
Practice Address - Street 1:23802 HIGHWAY 59 N
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-1510
Practice Address - Country:US
Practice Address - Phone:281-312-5400
Practice Address - Fax:281-312-5440
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP6191207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328359001Medicaid
TX299419YTTSMedicare PIN