Provider Demographics
NPI:1033653431
Name:JACKSON, KELLY (RN, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 WOODRUFF LN
Mailing Address - Street 2:
Mailing Address - City:SAN AUGUSTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75972-2637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9423 S US HIGHWAY 69
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:TX
Practice Address - Zip Code:75949-1515
Practice Address - Country:US
Practice Address - Phone:936-955-5540
Practice Address - Fax:936-955-5541
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily