Provider Demographics
NPI:1144608977
Name:JACKSON, MARISHA
Entity Type:Individual
Prefix:
First Name:MARISHA
Middle Name:
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 1:1261 KENMORE PL
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37216-3214
Mailing Address - Country:US
Mailing Address - Phone:615-801-3495
Mailing Address - Fax:
Practice Address - Street 1:1261 KENMORE PL
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37216-3214
Practice Address - Country:US
Practice Address - Phone:615-801-3495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)