Provider Demographics
NPI:1457540510
Name:MACKLING, JODY D (CPNP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:D
Last Name:MACKLING
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 MEDICAL DISTRICT DRIVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235
Mailing Address - Country:US
Mailing Address - Phone:214-456-8000
Mailing Address - Fax:
Practice Address - Street 1:1935 MEDICAL DISTRICT DRIVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235
Practice Address - Country:US
Practice Address - Phone:214-456-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX671189363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752616977118OtherTRICARE
TX886N35OtherBCBS
TX192349205Medicaid
TX75-2616977-027OtherTRICARE
TX855N92OtherBCBS
TX192349204Medicaid
TX752616977118OtherTRICARE
TXP00986451Medicare PIN
TX192349205Medicaid