Provider Demographics
NPI:1598985491
Name:STACKENS, TIFFANY LATESE
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:LATESE
Last Name:STACKENS
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 1:39 BROOKSIE DR
Mailing Address - Street 2:589 EAST COLLEGE ST
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3621
Mailing Address - Country:US
Mailing Address - Phone:731-660-5611
Mailing Address - Fax:
Practice Address - Street 1:804 N PARKWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3058
Practice Address - Country:US
Practice Address - Phone:731-423-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education