1871523308 NPI number — SHERYL R JACKSON PHD

Table of content: SHERYL R JACKSON PHD (NPI 1871523308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871523308 NPI number — SHERYL R JACKSON PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
SHERYL
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871523308
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2765 MESQUITE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAPEVINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76051-7166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-223-1026
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1215 HALL-JOHNSON RD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
COLLEYVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-909-7995
Provider Business Practice Location Address Fax Number:
817-428-9885
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  1447 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 33305 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R99502 . This is a "VIVA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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