Provider Demographics
NPI:1295157337
Name:PHOENIX HEALTH CENTER, PLLC
Entity type:Organization
Organization Name:PHOENIX HEALTH CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-595-5595
Mailing Address - Street 1:1114 W BOW ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-5137
Mailing Address - Country:US
Mailing Address - Phone:903-595-5595
Mailing Address - Fax:903-595-5985
Practice Address - Street 1:1114 W BOW ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5137
Practice Address - Country:US
Practice Address - Phone:903-595-5595
Practice Address - Fax:903-595-5985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-08
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty