Provider Demographics
NPI:1063669893
Name:JACKSON-BUTLER, MAHALIA L (DNP, APRN)
Entity type:Individual
Prefix:DR
First Name:MAHALIA
Middle Name:L
Last Name:JACKSON-BUTLER
Suffix:
Gender:F
Credentials:DNP, APRN
Other - Prefix:MRS
Other - First Name:MAHALIA
Other - Middle Name:L
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4621 S COOPER ST STE 131-717
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5866
Mailing Address - Country:US
Mailing Address - Phone:214-277-2243
Mailing Address - Fax:214-231-2926
Practice Address - Street 1:2721 CENTRAL DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-4810
Practice Address - Country:US
Practice Address - Phone:214-277-2243
Practice Address - Fax:214-231-2926
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX715590363LA2200X
TXAP117597363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201844201Medicaid
TX201844201Medicaid