Provider Demographics
NPI:1013220268
Name:JACKSON, CHERYL (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 BROWN SCHOOL CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-6727
Mailing Address - Country:US
Mailing Address - Phone:832-831-9390
Mailing Address - Fax:832-831-9392
Practice Address - Street 1:5002 S LAKE HOUSTON PKWY STE 7
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77049-2631
Practice Address - Country:US
Practice Address - Phone:832-831-9390
Practice Address - Fax:832-831-9392
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX673649363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB142016OtherMEDICARE