Provider Demographics
NPI:1568009926
Name:JACKSON, TONYALEE MARY
Entity Type:Individual
Prefix:MS
First Name:TONYALEE
Middle Name:MARY
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 1:74 OLD SUNDERLAND RD # A
Mailing Address - Street 2:
Mailing Address - City:MONTAGUE
Mailing Address - State:MA
Mailing Address - Zip Code:01351-9510
Mailing Address - Country:US
Mailing Address - Phone:413-800-2990
Mailing Address - Fax:
Practice Address - Street 1:74 OLD SUNDERLAND RD # A
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:MA
Practice Address - Zip Code:01351-9510
Practice Address - Country:US
Practice Address - Phone:413-800-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider