Provider Demographics
NPI:1588611560
Name:JACKSON, PEGGY SUE (FNP)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:SUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:SUE
Other - Last Name:HIGGINBOTHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7515 GREENVILLE AVE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-3831
Mailing Address - Country:US
Mailing Address - Phone:214-692-8262
Mailing Address - Fax:214-853-9415
Practice Address - Street 1:8230 WALNUT HILL LN
Practice Address - Street 2:SUITE 700
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4482
Practice Address - Country:US
Practice Address - Phone:214-691-1902
Practice Address - Fax:214-853-9415
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX509015363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P62366Medicare UPIN
TXTXB161353Medicare PIN
TXTXB161352Medicare PIN