Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 25807 | TX |
Y | 103TC0700X | Clinical Psychologist | 25807 | TX |
NPI | 1003859992 |
---|---|
Provider Name | Sarah Jane Jackson |
First Address | Austin, TX 78759-8661 |
Second Address | Austin, TX 78759-8661 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0073JB | BLUE CROSS BLUE SHIELD (01) | TX |
0401218-06 | (05) | TX |