Provider Demographics
NPI:1851938344
Name:JACKSON, MYSHONIQUE M (LVN)
Entity Type:Individual
Prefix:
First Name:MYSHONIQUE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41
Mailing Address - Street 2:
Mailing Address - City:PLEDGER
Mailing Address - State:TX
Mailing Address - Zip Code:77468-0041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12371 S KIRKWOOD RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-2836
Practice Address - Country:US
Practice Address - Phone:713-995-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX340301164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse