Provider Demographics
NPI:1093754673
Name:JACKSON, TOMMIE S
Entity Type:Individual
Prefix:MS
First Name:TOMMIE
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 W END BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-1120
Mailing Address - Country:US
Mailing Address - Phone:336-750-0130
Mailing Address - Fax:336-750-0073
Practice Address - Street 1:453 W END BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-1120
Practice Address - Country:US
Practice Address - Phone:336-750-0130
Practice Address - Fax:336-750-0073
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC925101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional