Provider Demographics
NPI:1780996850
Name:JACKSON, CHRISTY NICHOLE (CNM)
Entity type:Individual
Prefix:
First Name:CHRISTY
Middle Name:NICHOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:CHRISTY
Other - Middle Name:NICHOLE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-539-9582
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX743083367A00000X
NY001534367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife