Provider Demographics
NPI:1104447275
Name:JACKSON, NICOLE FELIZ (ATC, LAT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:FELIZ
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16613 J CHESHIER CT
Mailing Address - Street 2:
Mailing Address - City:JUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:76247-5778
Mailing Address - Country:US
Mailing Address - Phone:405-863-7464
Mailing Address - Fax:
Practice Address - Street 1:1301 S US HIGHWAY 377
Practice Address - Street 2:
Practice Address - City:ARGYLE
Practice Address - State:TX
Practice Address - Zip Code:76226-7744
Practice Address - Country:US
Practice Address - Phone:405-863-7464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT55232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer