Provider Demographics
NPI:1124583653
Name:JACKSON, TARA Y (CRNP SP020082)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:Y
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNP SP020082
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 BLAIR MILL RD
Mailing Address - Street 2:
Mailing Address - City:HORSHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19044-2223
Mailing Address - Country:US
Mailing Address - Phone:215-902-9014
Mailing Address - Fax:
Practice Address - Street 1:680 BLAIR MILL RD
Practice Address - Street 2:
Practice Address - City:HORSHAM
Practice Address - State:PA
Practice Address - Zip Code:19044-2223
Practice Address - Country:US
Practice Address - Phone:215-902-9014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN527439L163W00000X
PASP020082363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily