Basic Information
| Provider Information | |||||||||
| NPI: | 1972921500 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3480 COLLEGE ST | ||||||||
| Address2: | BEAUMONT | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098131677 | ||||||||
| FaxNumber: | 4097301399 | ||||||||
| Practice Location | |||||||||
| Address1: | 3480 COLLEGE ST | ||||||||
| Address2: | BEAUMONT | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098131677 | ||||||||
| FaxNumber: | 4097301399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2014 | ||||||||
| LastUpdateDate: | 04/28/2017 | ||||||||
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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 | 363LF0000X | AP125323 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 353166701 | 05 | TX | MEDICAID |