Provider Demographics
NPI:1659898351
Name:JACKSON, TAMARA RENEE (AAS, QMHS)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AAS, QMHS
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:RENEE
Other - Last Name:PALM-CROMBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AAS, QMHS
Mailing Address - Street 1:2587 BACK ORRVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-9523
Mailing Address - Country:US
Mailing Address - Phone:330-264-9597
Mailing Address - Fax:330-264-0946
Practice Address - Street 1:2587 BACK ORRVILLE RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-9523
Practice Address - Country:US
Practice Address - Phone:330-264-9597
Practice Address - Fax:330-264-0946
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator