Provider Demographics
NPI:1437920204
Name:BLOUNT-JACKSON, TANDELA SHAYONTAYE
Entity Type:Individual
Prefix:
First Name:TANDELA
Middle Name:SHAYONTAYE
Last Name:BLOUNT-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 1:120 ELLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32348-5200
Mailing Address - Country:US
Mailing Address - Phone:850-672-2628
Mailing Address - Fax:
Practice Address - Street 1:120 ELLINGTON ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32348-5200
Practice Address - Country:US
Practice Address - Phone:850-672-2628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker