Provider Demographics
NPI:1740546670
Name:JACKSON, LENITA C (RN)
Entity type:Individual
Prefix:
First Name:LENITA
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
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 590896
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77259-0896
Mailing Address - Country:US
Mailing Address - Phone:409-354-9701
Mailing Address - Fax:281-333-3686
Practice Address - Street 1:18511 EGRET BAY BLVD
Practice Address - Street 2:APT 105
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-3838
Practice Address - Country:US
Practice Address - Phone:409-354-9701
Practice Address - Fax:281-333-3686
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX789762163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse