Provider Demographics
NPI:1407311509
Name:JACKSON, TANISHA
Entity Type:Individual
Prefix:MS
First Name:TANISHA
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 1:1271 HOGANSVILLE RD APT 115
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-6667
Mailing Address - Country:US
Mailing Address - Phone:334-646-1574
Mailing Address - Fax:
Practice Address - Street 1:1271 HOGANSVILLE RD APT 115
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-6667
Practice Address - Country:US
Practice Address - Phone:334-646-1574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator