Provider Demographics
NPI:1457004863
Name:JACKSON, TASHEKA L
Entity Type:Individual
Prefix:
First Name:TASHEKA
Middle Name:L
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 1:4204 E MALLORY AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-7819
Mailing Address - Country:US
Mailing Address - Phone:901-649-0305
Mailing Address - Fax:601-340-9588
Practice Address - Street 1:4204 E MALLORY AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-7819
Practice Address - Country:US
Practice Address - Phone:901-649-0305
Practice Address - Fax:601-340-9588
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment