Provider Demographics
NPI:1093169823
Name:TARA JACKSON
Entity Type:Organization
Organization Name:TARA JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEVELOPMENTAL INTERVENTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-847-7004
Mailing Address - Street 1:104 G CORUM LN
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:KY
Mailing Address - Zip Code:42206-5000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 G CORUM LN
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:KY
Practice Address - Zip Code:42206-5000
Practice Address - Country:US
Practice Address - Phone:270-847-7004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency