Provider Demographics
NPI:1134608391
Name:JACKSON, BEVERLY J
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:J
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 1:817 BRIARCREEK DR
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77521-3473
Mailing Address - Country:US
Mailing Address - Phone:713-492-3531
Mailing Address - Fax:
Practice Address - Street 1:817 BRIARCREEK DR
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-3473
Practice Address - Country:US
Practice Address - Phone:713-492-3531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX582990163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse