Provider Demographics
NPI:1801362611
Name:JACKSON, TAMIKA LACHELLE (DNP, FNP, AG-ACNP)
Entity Type:Individual
Prefix:MS
First Name:TAMIKA
Middle Name:LACHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DNP, FNP, AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 PARNASSUS AVE FL 6
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2202
Mailing Address - Country:US
Mailing Address - Phone:415-353-1606
Mailing Address - Fax:415-353-1213
Practice Address - Street 1:400 PARNASSUS AVE STE 501
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2202
Practice Address - Country:US
Practice Address - Phone:415-353-1606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22285363LF0000X, 363LA2100X
CA95010766363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily