Provider Demographics
NPI:1689257008
Name:JACKSON, TAMAR DENISE
Entity Type:Individual
Prefix:
First Name:TAMAR
Middle Name:DENISE
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 1:840 YORK ST APT 16
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-2134
Mailing Address - Country:US
Mailing Address - Phone:510-717-0941
Mailing Address - Fax:
Practice Address - Street 1:840 YORK ST APT 16
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-2134
Practice Address - Country:US
Practice Address - Phone:510-717-0941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty