Provider Demographics
NPI:1871002857
Name:JACKSON, SHERRELLE PRINCESS (DNP)
Entity Type:Individual
Prefix:
First Name:SHERRELLE
Middle Name:PRINCESS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 ALLEN PARK WAY
Mailing Address - Street 2:4088
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77019
Mailing Address - Country:US
Mailing Address - Phone:843-622-7043
Mailing Address - Fax:
Practice Address - Street 1:6701 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2608
Practice Address - Country:US
Practice Address - Phone:832-822-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2017005851363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner