Provider Demographics
NPI:1689239147
Name:MERCK, JACKIE L
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:L
Last Name:MERCK
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 1:721 W HERON ST
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-6115
Mailing Address - Country:US
Mailing Address - Phone:754-779-0182
Mailing Address - Fax:
Practice Address - Street 1:721 W HERON ST
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-6115
Practice Address - Country:US
Practice Address - Phone:754-779-0182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX133249164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse