Provider Demographics
NPI:1235294018
Name:JACKSON, TAMMY J (LICENSED PSYCHOLOGIS)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LICENSED PSYCHOLOGIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1272 NE WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5594
Mailing Address - Country:US
Mailing Address - Phone:816-246-4465
Mailing Address - Fax:
Practice Address - Street 1:1272 NE WINDSOR DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-5594
Practice Address - Country:US
Practice Address - Phone:816-246-4465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01757103TC1900X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO22842017OtherPROVIDER NUMBER
MOH029218Medicare ID - Type Unspecified