Provider Demographics
NPI:1225426224
Name:JACKSON, TIERRA
Entity Type:Individual
Prefix:
First Name:TIERRA
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 1:1500 PRIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-9157
Mailing Address - Country:US
Mailing Address - Phone:270-821-1813
Mailing Address - Fax:270-825-2644
Practice Address - Street 1:1500 PRIDE AVE
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-9157
Practice Address - Country:US
Practice Address - Phone:270-821-1813
Practice Address - Fax:270-825-2644
Is Sole Proprietor?:No
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA5898224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant