Provider Demographics
NPI:1588905541
Name:JACKSON, MIRIAM M (PNP)
Entity type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:E
Other - Last Name:MURILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7940 SHOAL CREEK BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-7589
Mailing Address - Country:US
Mailing Address - Phone:512-494-4000
Mailing Address - Fax:512-494-4024
Practice Address - Street 1:7940 SHOAL CREEK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-7589
Practice Address - Country:US
Practice Address - Phone:512-494-4000
Practice Address - Fax:512-494-4024
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP123315363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX324615902Medicaid
TX324615901Medicaid
TX294559YKZJMedicare PIN