Provider Demographics
NPI:1235322793
Name:PITTS-JACKSON, TANYA MONIQUE (MEDICAL ASSISTANT)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:MONIQUE
Last Name:PITTS-JACKSON
Suffix:
Gender:F
Credentials:MEDICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-4224
Mailing Address - Country:US
Mailing Address - Phone:610-490-0476
Mailing Address - Fax:
Practice Address - Street 1:5700 KIRKWOOD HWY
Practice Address - Street 2:SUITE 203
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-4857
Practice Address - Country:US
Practice Address - Phone:302-998-0469
Practice Address - Fax:302-998-0298
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-19
Last Update Date:2007-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant