Provider Demographics
NPI:1295536159
Name:JACKSON, TENIOLA YETUNDE
Entity type:Individual
Prefix:
First Name:TENIOLA
Middle Name:YETUNDE
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25906 AURA LAKE LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-1722
Mailing Address - Country:US
Mailing Address - Phone:832-283-9308
Mailing Address - Fax:
Practice Address - Street 1:13523 HARGRAVE RD STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-3829
Practice Address - Country:US
Practice Address - Phone:346-654-3463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1193049363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care