Provider Demographics
NPI:1659918878
Name:JACKSON, AMBER DAWN (LVN)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:DAWN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 SW TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-3813
Mailing Address - Country:US
Mailing Address - Phone:817-965-1267
Mailing Address - Fax:
Practice Address - Street 1:117 SW TAYLOR ST
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-3813
Practice Address - Country:US
Practice Address - Phone:817-965-1267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX204184164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse