Provider Demographics
NPI:1083140891
Name:JACKSON, NIKI ROSE (MD)
Entity type:Individual
Prefix:
First Name:NIKI
Middle Name:ROSE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3032 MARINA BAY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-4668
Mailing Address - Country:US
Mailing Address - Phone:832-604-6534
Mailing Address - Fax:832-604-6531
Practice Address - Street 1:3032 MARINA BAY DR STE 200
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-4668
Practice Address - Country:US
Practice Address - Phone:832-604-6534
Practice Address - Fax:832-604-6531
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT4184207R00000X, 207R00000X
AZ58143208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine