Provider Demographics
NPI:1669828224
Name:JACKSON, STACEY RENEE (NP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 W RANDOL MILL RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2510
Mailing Address - Country:US
Mailing Address - Phone:817-261-4906
Mailing Address - Fax:817-261-5837
Practice Address - Street 1:906 W RANDOL MILL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2510
Practice Address - Country:US
Practice Address - Phone:817-261-4906
Practice Address - Fax:817-261-5837
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130643363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX509731YKPWMedicare PIN
TX509731YKQLMedicare PIN