Provider Demographics
NPI:1821495961
Name:JACKSON, TONJANIKA (PHD)
Entity Type:Individual
Prefix:DR
First Name:TONJANIKA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3633 WHEELER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6550
Mailing Address - Country:US
Mailing Address - Phone:706-364-0252
Mailing Address - Fax:706-364-0269
Practice Address - Street 1:3633 WHEELER RD STE 100
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6550
Practice Address - Country:US
Practice Address - Phone:706-364-0252
Practice Address - Fax:706-364-0269
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACPD0044101YA0400X
GALPC006878101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1518487529OtherNPI