Provider Demographics
NPI:1497347744
Name:JACKSON, TONYA
Entity Type:Individual
Prefix:MS
First Name:TONYA
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 1:1265 RIVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-2024
Mailing Address - Country:US
Mailing Address - Phone:757-769-9640
Mailing Address - Fax:757-937-8771
Practice Address - Street 1:1265 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2024
Practice Address - Country:US
Practice Address - Phone:757-769-9640
Practice Address - Fax:757-937-8771
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 376J00000X
VA376K00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty