Basic Information
Provider Information
NPI: 1033556170
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MCDONALD
FirstName: JACKIE
MiddleName: LYNN
NamePrefix:  
NameSuffix:  
Credential: RN, COHN-S, CAOHC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163W00000X660165TXN Nursing Service ProvidersRegistered Nurse 
163WX0106X660165TXY Nursing Service ProvidersRegistered NurseOccupational Health
246Z00000X40275 N Technologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other 

ID Information
IDTypeStateIssuerDescription
4027501 CAOHCOTHER
892201 COHN-SOTHER
66016501TXRNOTHER


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