Provider Demographics
NPI:1598874406
Name:WHITE JACKSON, TANIA A (MD)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:A
Last Name:WHITE JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 W PARKER RD
Mailing Address - Street 2:BUILDING 2, SUITE 325
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8100
Mailing Address - Country:US
Mailing Address - Phone:972-981-3535
Mailing Address - Fax:
Practice Address - Street 1:6300 W PARKER RD
Practice Address - Street 2:BUILDING 2, SUITE 325
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8100
Practice Address - Country:US
Practice Address - Phone:972-981-3535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9439207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN752905791OtherTIN
TXF77381Medicare UPIN