Provider Demographics
NPI:1952735391
Name:JACKSON, GWENDOLYN FAYE (CNA)
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:FAYE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5743 FARWELL DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77035
Mailing Address - Country:US
Mailing Address - Phone:832-207-5272
Mailing Address - Fax:713-485-0804
Practice Address - Street 1:5743 FARWELL DR.
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77035
Practice Address - Country:US
Practice Address - Phone:832-207-5272
Practice Address - Fax:713-485-0804
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA00411498376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide