Provider Demographics
NPI:1558023572
Name:JACKSON, TONYA L (NP)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75462-7400
Mailing Address - Country:US
Mailing Address - Phone:903-785-3400
Mailing Address - Fax:
Practice Address - Street 1:4650 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75462-7400
Practice Address - Country:US
Practice Address - Phone:903-785-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1056041363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology