Provider Demographics
NPI:1962688093
Name:JACKMAN, RHONDA LEE (CPNP)
Entity Type:Individual
Prefix:MS
First Name:RHONDA
Middle Name:LEE
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 STONY BROOK LN
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-1342
Mailing Address - Country:US
Mailing Address - Phone:972-926-9373
Mailing Address - Fax:
Practice Address - Street 1:9101 N CENTRAL EXPY STE 420
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5945
Practice Address - Country:US
Practice Address - Phone:214-823-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX535375363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2014169-01Medicaid
TX2014169-01Medicaid