Provider Demographics
NPI:1366127193
Name:JACKSON, RITA MICHELE
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:MICHELE
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 1:1112 ROSEDALE SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76134-8471
Mailing Address - Country:US
Mailing Address - Phone:817-806-7032
Mailing Address - Fax:
Practice Address - Street 1:3529 DENTON HWY STE D
Practice Address - Street 2:
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76117-3293
Practice Address - Country:US
Practice Address - Phone:817-759-0707
Practice Address - Fax:817-759-0828
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1010664164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse