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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:LAUREL FORK
Mailing Address - State:VA
Mailing Address - Zip Code:24352-0009
Mailing Address - Country:US
Mailing Address - Phone:276-398-1200
Mailing Address - Fax:
Practice Address - Street 1:14558 DANVILLE PIKE
Practice Address - Street 2:
Practice Address - City:LAUREL FORK
Practice Address - State:VA
Practice Address - Zip Code:24352-3982
Practice Address - Country:US
Practice Address - Phone:276-398-2292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2025-07-24
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