Provider Demographics
NPI:1548843527
Name:JACKSON, VINEY
Entity type:Individual
Prefix:
First Name:VINEY
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 1:3701 ALTAMESA BLVD # 331652
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-5649
Mailing Address - Country:US
Mailing Address - Phone:682-582-3985
Mailing Address - Fax:682-224-2997
Practice Address - Street 1:6901 LOMA VISTA DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-6428
Practice Address - Country:US
Practice Address - Phone:682-253-4807
Practice Address - Fax:682-224-2997
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20201004P3747P1801X
3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider