Basic Information
| Provider Information | |||||||||
| NPI: | 1811281504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | CHELSI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246400 | ||||||||
| FaxNumber: | 9038775080 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 ZEID BLVD | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756526070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036577583 | ||||||||
| FaxNumber: | 9039038775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2011 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | BP10041306 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | P9882 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.