Provider Demographics
NPI:1558345371
Name:JACKSON, TAMMY Z (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:Z
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-2909
Mailing Address - Country:US
Mailing Address - Phone:662-837-1534
Mailing Address - Fax:662-837-3274
Practice Address - Street 1:716 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-2909
Practice Address - Country:US
Practice Address - Phone:662-837-1534
Practice Address - Fax:662-837-3274
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR613401363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112669Medicaid
331328YVARMedicare Oscar/Certification
MS00112669Medicaid