Provider Demographics
NPI:1194292441
Name:JACKSON, LISA (PCA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SMITH ST # 61070
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-7871
Mailing Address - Country:US
Mailing Address - Phone:832-484-2740
Mailing Address - Fax:
Practice Address - Street 1:2423 MONTANA BLUE DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77373-7871
Practice Address - Country:US
Practice Address - Phone:832-484-2740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82-4881025Medicaid