Provider Demographics
NPI:1073499661
Name:JACKSON, CHANTEL
Entity type:Individual
Prefix:
First Name:CHANTEL
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 1:224 SLIPPERY ELM DR
Mailing Address - Street 2:
Mailing Address - City:NOLANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76559-4735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3909 N LOOP 288 APT 7211
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76208-7113
Practice Address - Country:US
Practice Address - Phone:817-205-2404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-12
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No171M00000XOther Service ProvidersCase Manager/Care Coordinator