Provider Demographics
NPI:1497783146
Name:JACKSON, TAMMY T (FNP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 GLENWOOD DRIVE
Mailing Address - Street 2:SUITE E-487
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404
Mailing Address - Country:US
Mailing Address - Phone:423-697-0014
Mailing Address - Fax:423-648-6280
Practice Address - Street 1:2525 DESALES AVENUE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404
Practice Address - Country:US
Practice Address - Phone:423-697-0014
Practice Address - Fax:423-648-6280
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN07265363L00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA616596673AMedicaid
TNS69670Medicare UPIN
TN3903352Medicare ID - Type Unspecified
GA616596673AMedicaid