Jackie Ijeoma Penn, NP

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

1056737 Issued in TX

Practice address

5319 Nueces LN
Grand Prairie, TX 75052-2667

Phone

(214) 584-4103

NPI assigned

May 28, 2013

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2021

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Rosebud Indian Health ServiceGroup PAC ID 6901704055, 76 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• PHS Indian Hospital at Rosebud Hospital, Rosebud, SD, CCN 430084

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Rosebud Indian Health Service

  • General Acute Care Hospital
  • Rosebud, SD
  • NPI 1194757369

  TX

  Medicare reassignment Care Compare group NPD
• US Televero Health PA

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Austin, TX
  • NPI 1992318992

  Psychiatric/Mental Health

  Medicare reassignment NPD
• Pine Ridge Indian Health Service Hospital

  • Clinic/Center
  • Kyle, SD
  • NPI 1003963497

  TX

  Medicare reassignment NPD
• Calmcare Behavioral and Wellness Center LLC

  • Psychiatric/Mental Health Nurse Practitioner
  • Garland, TX
  • NPI 1871308056
  NPD Authorized official
• Rosebud Indian Health Service

  • Ambulatory Surgical Clinic/Center
  • Rosebud, SD
  • NPI 1790955128
  NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Rosebud Indian Health Service

  • General Acute Care Hospital
  • Rosebud, SD
  • NPI 1427419282
  Care Compare affiliation Name & address match

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1369699200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1714694400000",
    "number": "1972940260",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5319 NUECES LN",
            "city": "GRAND PRAIRIE",
            "state": "TX",
            "postal_code": "750522667",
            "telephone_number": "214-584-4103"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5319 NUECES LN",
            "city": "GRAND PRAIRIE",
            "state": "TX",
            "postal_code": "750522667",
            "telephone_number": "214-584-4103"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PENN",
        "first_name": "JACKIE",
        "middle_name": "IJEOMA",
        "credential": "NP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2013-05-28",
        "last_updated": "2024-05-03",
        "certification_date": "2022-08-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "TX",
            "license": "783349",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "TX",
            "license": "1056737",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Peculiar Wellness Center LLC
• Erica Ann Peddy
• Pediatric Center of Grand Prairie
• Laurent Pelletier, DC
• Penn Dental Partners PLLC
• Tamara Penny, OT
• Rodnesha Markalon Penson, LVN/LPN
• Pep Research Enterprises Inc.
• Joshua Peralta
• Bianca Perez-Ruiz, LMSW

• Psychiatric/Mental Health Nurse Practitioner in Grand Prairie, TX
• Providers in Grand Prairie, TX by specialty
• Psychiatric/Mental Health Nurse Practitioner in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 3, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.