Provider Demographics
NPI:1740896315
Name:JACKSON, MACKENZIE BROOKS
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:BROOKS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 N CREEKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-7540
Mailing Address - Country:US
Mailing Address - Phone:281-744-0412
Mailing Address - Fax:
Practice Address - Street 1:46 N CREEKSIDE CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-7540
Practice Address - Country:US
Practice Address - Phone:281-744-0412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-19
Last Update Date:2020-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142710363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care