Provider Demographics
NPI:1871523308
Name:JACKSON, SHERYL R (PHD)
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2765 MESQUITE LN
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-7166
Mailing Address - Country:US
Mailing Address - Phone:682-223-1026
Mailing Address - Fax:
Practice Address - Street 1:1215 HALL-JOHNSON RD
Practice Address - Street 2:STE 100
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034
Practice Address - Country:US
Practice Address - Phone:817-909-7995
Practice Address - Fax:817-428-9885
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1447103TC0700X
TX33305103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALR99502OtherVIVA