Provider Demographics
NPI:1790909653
Name:JACKSON, TANIESHA M
Entity Type:Individual
Prefix:
First Name:TANIESHA
Middle Name:M
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 1:2914 CAMBRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-3018
Mailing Address - Country:US
Mailing Address - Phone:440-585-7661
Mailing Address - Fax:
Practice Address - Street 1:1835 BELMORE RD
Practice Address - Street 2:
Practice Address - City:EAST CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-4301
Practice Address - Country:US
Practice Address - Phone:216-268-3600
Practice Address - Fax:216-851-7363
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP8464235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist