Provider Demographics
NPI:1881805034
Name:JACKSON, MARNIE (MD)
Entity type:Individual
Prefix:
First Name:MARNIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 ARROYO BLVD
Mailing Address - Street 2:BOX 529
Mailing Address - City:RIO HONDO
Mailing Address - State:TX
Mailing Address - Zip Code:78583-4165
Mailing Address - Country:US
Mailing Address - Phone:956-226-8389
Mailing Address - Fax:
Practice Address - Street 1:606 S ARROYO BLVD, PO BOX 529
Practice Address - Street 2:
Practice Address - City:RIO HONDO
Practice Address - State:TX
Practice Address - Zip Code:78583-4165
Practice Address - Country:US
Practice Address - Phone:956-226-8389
Practice Address - Fax:956-630-6643
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN0852207L00000X, 207LP3000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197710006OtherCSHCN
TX197710005Medicaid
TX197710003Medicaid
BP1-0018388OtherINSTITUTIONAL PERMIT
TX8BX291OtherBCBS
TXN0852OtherSTATE LIC
BP1-0018388OtherINSTITUTIONAL PERMIT
TX8BX291OtherBCBS