Provider Demographics
NPI:1023587722
Name:JACKSON, MORYA KOQUESE
Entity type:Individual
Prefix:
First Name:MORYA
Middle Name:KOQUESE
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 1:9550 FOREST LN STE 310
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-5906
Mailing Address - Country:US
Mailing Address - Phone:214-785-2388
Mailing Address - Fax:214-377-9542
Practice Address - Street 1:9550 FOREST LN STE 310
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-5906
Practice Address - Country:US
Practice Address - Phone:214-337-9436
Practice Address - Fax:214-337-9542
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251J00000XAgenciesNursing Care
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
No385H00000XRespite Care FacilityRespite Care