Provider Demographics
NPI:1184123663
Name:JIMMERSON, KIZZIE (CNA, RCMA)
Entity type:Individual
Prefix:
First Name:KIZZIE
Middle Name:
Last Name:JIMMERSON
Suffix:
Gender:F
Credentials:CNA, RCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 GREENS RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-1417
Mailing Address - Country:US
Mailing Address - Phone:281-570-8444
Mailing Address - Fax:
Practice Address - Street 1:838 GREENS RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-1417
Practice Address - Country:US
Practice Address - Phone:128-157-0844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA835949376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82-4358303Medicaid