Provider Demographics
NPI:1245977503
Name:JACKSON, TAICAERIA TA'RAI
Entity type:Individual
Prefix:
First Name:TAICAERIA
Middle Name:TA'RAI
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4526 VERONA HILLS LN
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-2990
Mailing Address - Country:US
Mailing Address - Phone:281-978-0460
Mailing Address - Fax:
Practice Address - Street 1:6930 FM 1960 RD W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77069-3702
Practice Address - Country:US
Practice Address - Phone:281-836-6085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1021096363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner