Provider Demographics
NPI:1093736720
Name:JACKSON, TAMMY S (NP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 20TH AVE N
Mailing Address - Street 2:STE 301
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2131
Mailing Address - Country:US
Mailing Address - Phone:615-329-0570
Mailing Address - Fax:
Practice Address - Street 1:300 20TH AVE N
Practice Address - Street 2:STE 301
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2131
Practice Address - Country:US
Practice Address - Phone:615-329-0570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN113718363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3901205Medicaid
TN3901205Medicaid
3901205Medicare ID - Type Unspecified