Provider Demographics
NPI:1902110521
Name:JACKSON, JUANITA
Entity Type:Individual
Prefix:MS
First Name:JUANITA
Middle Name:
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 1:11000 CORPORATE CENTRE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-5167
Mailing Address - Country:US
Mailing Address - Phone:713-983-2082
Mailing Address - Fax:
Practice Address - Street 1:11000 CORPORATE CENTRE DR STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77041-5167
Practice Address - Country:US
Practice Address - Phone:713-983-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106198183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician