Provider Demographics
NPI:1679723977
Name:JACKSON, TINA (LPN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ARDEN LN APT A
Mailing Address - Street 2:
Mailing Address - City:EASTAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-3371
Mailing Address - Country:US
Mailing Address - Phone:800-950-6066
Mailing Address - Fax:
Practice Address - Street 1:1 ARDEN LN APT A
Practice Address - Street 2:
Practice Address - City:EASTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-3371
Practice Address - Country:US
Practice Address - Phone:800-950-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP05502400164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse