Provider Demographics
NPI:1356864565
Name:JACKSON, TORIELLA (CPRS)
Entity Type:Individual
Prefix:
First Name:TORIELLA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 NORTH CLEVELAND
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104
Mailing Address - Country:US
Mailing Address - Phone:1901-725-9005
Mailing Address - Fax:
Practice Address - Street 1:135 N CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2002
Practice Address - Country:US
Practice Address - Phone:901-725-9005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000-689175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty