Basic Information
| Provider Information | |||||||||
| NPI: | 1033556170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | JACKIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | RN, COHN-S, CAOHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11937 HWY 271 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757083154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038775553 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11937 HWY 271 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757083154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038775553 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2013 | ||||||||
| LastUpdateDate: | 05/30/2013 | ||||||||
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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 | 163W00000X | 660165 | TX | N | Nursing Service Providers | Registered Nurse | 163WX0106X | 660165 | TX | Y | Nursing Service Providers | Registered Nurse | Occupational Health | 246Z00000X | 40275 | N | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other |
ID Information
| ID | Type | State | Issuer | Description | 660165 | 01 | TX | RN | OTHER | 40275 | 01 | CAOHC | OTHER | 8922 | 01 | COHN-S | OTHER |