Provider Demographics
NPI:1558077966
Name:JACKSON, TANYA RACHELL
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:RACHELL
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 1:203 N MADISON RD APT F
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:OH
Mailing Address - Zip Code:43140-2012
Mailing Address - Country:US
Mailing Address - Phone:740-506-1005
Mailing Address - Fax:
Practice Address - Street 1:203 N MADISON RD APT F
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-2012
Practice Address - Country:US
Practice Address - Phone:740-506-1005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker