Provider Demographics
NPI:1184272064
Name:NIELSEN, JACKIE T (LVN)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:T
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 CROWNHILL BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-1128
Mailing Address - Country:US
Mailing Address - Phone:210-824-5530
Mailing Address - Fax:
Practice Address - Street 1:105 LEMONWOOD AVE
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-4206
Practice Address - Country:US
Practice Address - Phone:210-544-6259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX306512164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse