Provider Demographics
NPI:1700237351
Name:JACKSON, YUTASHA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:YUTASHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CHATHAM CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5021
Mailing Address - Country:US
Mailing Address - Phone:817-455-2757
Mailing Address - Fax:
Practice Address - Street 1:903 CYPRESS CT
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-1354
Practice Address - Country:US
Practice Address - Phone:817-455-2757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX827023163W00000X, 163WA2000X, 163WC0400X, 163WC1500X, 163WH0200X, 163WP0200X, 163WP0807X, 163WP0808X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult