Provider Demographics
NPI:1144068248
Name:JACKSON, CANDACE NICOLE (MED)
Entity type:Individual
Prefix:MISS
First Name:CANDACE
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E LAMAR BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-4463
Mailing Address - Country:US
Mailing Address - Phone:972-670-7787
Mailing Address - Fax:
Practice Address - Street 1:1601 E LAMAR BLVD STE 204
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-4463
Practice Address - Country:US
Practice Address - Phone:972-670-7787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach