Provider Demographics
NPI:1053872036
Name:JACKSON-TUCKER, MICHELLE EBONG (APRN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:EBONG
Last Name:JACKSON-TUCKER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:3525 FM 2484
Practice Address - Street 2:
Practice Address - City:SALADO
Practice Address - State:TX
Practice Address - Zip Code:76571-6169
Practice Address - Country:US
Practice Address - Phone:254-947-7500
Practice Address - Fax:254-947-7521
Is Sole Proprietor?:No
Enumeration Date:2019-03-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141208363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily