Provider Demographics
NPI:1639301682
Name:JACKSON, GINA MARIE
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:JACKSON
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 1:12400 SHADOW CREEK PKWY
Mailing Address - Street 2:APT 2406
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7360
Mailing Address - Country:US
Mailing Address - Phone:713-995-9292
Mailing Address - Fax:713-995-4402
Practice Address - Street 1:12371 S KIRKWOOD RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-2836
Practice Address - Country:US
Practice Address - Phone:713-995-9292
Practice Address - Fax:713-995-4402
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102683225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics