Provider Demographics
NPI:1801346150
Name:JACKSON, KENYA
Entity type:Individual
Prefix:
First Name:KENYA
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 1:19002 MISSION PARK DR
Mailing Address - Street 2:APT 128
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-3101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19002 MISSION PARK DR
Practice Address - Street 2:APT 128
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-3101
Practice Address - Country:US
Practice Address - Phone:832-545-1843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP131762363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily