Basic Information
Provider Information | |||||||||
NPI: | 1386807832 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON-PAREKH | ||||||||
FirstName: | ROSEANNA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 161242 | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787161242 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5128003187 | ||||||||
FaxNumber: | 5122924458 | ||||||||
Practice Location | |||||||||
Address1: | 1215 RED RIVER ST | ||||||||
Address2: | STE 427 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787011921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5125551234 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/04/2008 | ||||||||
LastUpdateDate: | 05/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N0126 | TX | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 8BR430 | 01 | TX | BCBS | OTHER |