Provider Demographics
NPI:1649758947
Name:JACKSON, TYSHEKA
Entity Type:Individual
Prefix:
First Name:TYSHEKA
Middle Name:
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 1:2531 PARK HEIGHTS TER
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-7004
Mailing Address - Country:US
Mailing Address - Phone:443-538-0189
Mailing Address - Fax:
Practice Address - Street 1:2531 PARK HEIGHTS TER
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-7004
Practice Address - Country:US
Practice Address - Phone:443-538-0189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician