Provider Demographics
NPI:1457099301
Name:THOMAS, JACKIE MARIE (NP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:MARIE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1446
Mailing Address - Street 2:
Mailing Address - City:SPRINGTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:76082-1446
Mailing Address - Country:US
Mailing Address - Phone:817-523-1180
Mailing Address - Fax:
Practice Address - Street 1:4159 FM 2123
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:TX
Practice Address - Zip Code:76073-4323
Practice Address - Country:US
Practice Address - Phone:806-632-5704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-21
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1074023363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily