Provider Demographics
NPI:1982883609
Name:JACKSON, TRACIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 W LEAGUE CITY PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-7340
Mailing Address - Country:US
Mailing Address - Phone:281-332-8400
Mailing Address - Fax:281-476-6429
Practice Address - Street 1:1507 W LEAGUE CITY PKWY STE 100
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-7340
Practice Address - Country:US
Practice Address - Phone:281-332-8400
Practice Address - Fax:281-476-6429
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice