Provider Demographics
NPI:1962903468
Name:JACKSON, FOLASHADE AGNES
Entity type:Individual
Prefix:
First Name:FOLASHADE
Middle Name:AGNES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16406 COLTS BAY
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:TX
Mailing Address - Zip Code:78154-3895
Mailing Address - Country:US
Mailing Address - Phone:240-291-3145
Mailing Address - Fax:
Practice Address - Street 1:7330 SAN PEDRO AVE STE 800
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6268
Practice Address - Country:US
Practice Address - Phone:210-733-0524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX309224164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse