Provider Demographics
NPI:1578784245
Name:JACKSON, TARA M
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:M
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 1:104 G CORUM LN
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:KY
Mailing Address - Zip Code:42206-5000
Mailing Address - Country:US
Mailing Address - Phone:270-847-7004
Mailing Address - Fax:270-542-2519
Practice Address - Street 1:104 G CORUM LN
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:KY
Practice Address - Zip Code:42206-5000
Practice Address - Country:US
Practice Address - Phone:270-847-7004
Practice Address - Fax:270-542-2519
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist