Provider Demographics
NPI:1720367584
Name:JACKSON, WENDY LYNN (RN,, BA)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN,, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 MERMAID CIR
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-1875
Mailing Address - Country:US
Mailing Address - Phone:214-334-9444
Mailing Address - Fax:214-501-4380
Practice Address - Street 1:2213 MERMAID CIR
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-1875
Practice Address - Country:US
Practice Address - Phone:214-334-9444
Practice Address - Fax:214-501-4380
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX663334163WH0200X, 163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy