Provider Demographics
NPI:1508461708
Name:JACKSON, TEONNA
Entity Type:Individual
Prefix:
First Name:TEONNA
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 1:2008 TUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15219-5824
Mailing Address - Country:US
Mailing Address - Phone:412-339-0490
Mailing Address - Fax:
Practice Address - Street 1:2008 TUSTIN ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15219-5824
Practice Address - Country:US
Practice Address - Phone:412-339-0490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA49223601374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide