Provider Demographics
NPI:1073161642
Name:JACKSON, TIFFANY MICHELLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-2428
Mailing Address - Country:US
Mailing Address - Phone:540-639-5300
Mailing Address - Fax:
Practice Address - Street 1:600 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-2428
Practice Address - Country:US
Practice Address - Phone:540-639-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001197595163W00000X
VA0024178133363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse