Provider Demographics
NPI:1417656737
Name:JACKSON, TAMIKA
Entity Type:Individual
Prefix:
First Name:TAMIKA
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 1:5031 E CAPITOL ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-5327
Mailing Address - Country:US
Mailing Address - Phone:202-607-8759
Mailing Address - Fax:
Practice Address - Street 1:1221 M ST NW APT 604
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20005-5149
Practice Address - Country:US
Practice Address - Phone:202-607-8759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant