Provider Demographics
NPI:1144406075
Name:JACKSON, TASHA ROSE
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:ROSE
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 1:18 IPSWICH PL
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2316
Mailing Address - Country:US
Mailing Address - Phone:856-357-4148
Mailing Address - Fax:
Practice Address - Street 1:400 MARKET ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08102-1526
Practice Address - Country:US
Practice Address - Phone:856-541-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health