Provider Demographics
NPI:1568055481
Name:JACKSON, BOBBIE (MSN, APRN, AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:BOBBIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MSN, APRN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 W COLORADO BLVD STE 525
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2312
Mailing Address - Country:US
Mailing Address - Phone:214-960-5681
Mailing Address - Fax:214-960-5681
Practice Address - Street 1:221 W COLORADO BLVD STE 525
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2312
Practice Address - Country:US
Practice Address - Phone:214-960-5681
Practice Address - Fax:214-960-5681
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1029618363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care