Provider Demographics
NPI:1568973402
Name:JACKSON, TIFFANI (RSW)
Entity Type:Individual
Prefix:MS
First Name:TIFFANI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 AVENUE L
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-4143
Mailing Address - Country:US
Mailing Address - Phone:985-750-6839
Mailing Address - Fax:
Practice Address - Street 1:106 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726
Practice Address - Country:US
Practice Address - Phone:888-417-5250
Practice Address - Fax:225-341-8756
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0OtherN/A