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Individual
TARA RENAE JACKSON
Active
Individual
TARA RENAE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
742952
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
288779601
—
TX
01
—
8340UC
BCBS
TX
01
—
P01012907
RAILROAD
TX
Enumeration date
10/31/2011
Last updated
09/20/2013
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