Provider Demographics
NPI:1043542236
Name:JACKSON, TAMARA JEAN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:JEAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 HENRY AVE
Mailing Address - Street 2:
Mailing Address - City:WEWAHITCHKA
Mailing Address - State:FL
Mailing Address - Zip Code:32465-8766
Mailing Address - Country:US
Mailing Address - Phone:850-639-6211
Mailing Address - Fax:
Practice Address - Street 1:350 HENRY AVE
Practice Address - Street 2:
Practice Address - City:WEWAHITCHKA
Practice Address - State:FL
Practice Address - Zip Code:32465-8766
Practice Address - Country:US
Practice Address - Phone:850-639-6211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA36032172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker