Provider Demographics
NPI:1710519293
Name:JACKSON, TISHA JANEE'
Entity Type:Individual
Prefix:MISS
First Name:TISHA
Middle Name:JANEE'
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LESTINE
Other - Middle Name:VIRGINIA
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3720 S ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-2115
Mailing Address - Country:US
Mailing Address - Phone:202-749-5053
Mailing Address - Fax:
Practice Address - Street 1:3720 S ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2115
Practice Address - Country:US
Practice Address - Phone:202-749-5053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCIIII3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant