Provider Demographics
NPI:1205400397
Name:JACKSON, TIFFANY MARIE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
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 1:198 ELLEN DR
Mailing Address - Street 2:
Mailing Address - City:EVINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24550-3587
Mailing Address - Country:US
Mailing Address - Phone:757-955-5968
Mailing Address - Fax:
Practice Address - Street 1:20566 TIMBERLAKE RD STE A
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-7221
Practice Address - Country:US
Practice Address - Phone:434-239-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional