Provider Demographics
NPI:1689488108
Name:JACKSON, JAMONICA
Entity type:Individual
Prefix:
First Name:JAMONICA
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 1:3900 TELLURIDE WAY
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77807-7572
Mailing Address - Country:US
Mailing Address - Phone:979-271-0672
Mailing Address - Fax:
Practice Address - Street 1:3900 TELLURIDE WAY
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77807-7572
Practice Address - Country:US
Practice Address - Phone:979-271-0672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide