1881805034 NPI number — MARNIE JACKSON MD

Table of content: MARNIE JACKSON MD (NPI 1881805034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881805034 NPI number — MARNIE JACKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
MARNIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1881805034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
606 ARROYO BLVD
Provider Second Line Business Mailing Address:
BOX 529
Provider Business Mailing Address City Name:
RIO HONDO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78583-4165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-226-8389
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
606 S ARROYO BLVD, PO BOX 529
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIO HONDO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78583-4165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-226-8389
Provider Business Practice Location Address Fax Number:
956-630-6643
Provider Enumeration Date:
05/26/2007

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: N0852 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207LP3000X , with the licence number: N0852 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: N0852 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 197710006 . This is a "CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 197710005 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 197710003 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: BP1-0018388 . This is a "INSTITUTIONAL PERMIT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8BX291 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: N0852 . This is a "STATE LIC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 013196000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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