Provider Demographics
NPI:1710418355
Name:JACKSON, KIMBERLY (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 HIGH STAR DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75041-3236
Mailing Address - Country:US
Mailing Address - Phone:214-727-5725
Mailing Address - Fax:
Practice Address - Street 1:204 COIT RD STE 200
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-5718
Practice Address - Country:US
Practice Address - Phone:214-727-5725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist