Provider Demographics
NPI:1619958758
Name:JACKSON, TAMMY LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 SUN MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-7291
Mailing Address - Country:US
Mailing Address - Phone:979-217-1311
Mailing Address - Fax:855-604-0969
Practice Address - Street 1:1014 SUN MEADOW CT
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-7291
Practice Address - Country:US
Practice Address - Phone:979-217-1311
Practice Address - Fax:855-604-0969
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31418103TB0200X, 103TA0700X
103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158249604Medicaid
TX611932Medicare ID - Type Unspecified