Provider Demographics
NPI:1922740604
Name:JACKSON, KELLY TEAGUE (APRN, FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:TEAGUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3111 SUNNY KNOLL CT
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-3637
Mailing Address - Country:US
Mailing Address - Phone:832-701-7451
Mailing Address - Fax:
Practice Address - Street 1:10961 NORTHWEST FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77092-7305
Practice Address - Country:US
Practice Address - Phone:713-686-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1073035363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily