Provider Demographics
NPI:1912551227
Name:JACKSON, TAMIESHA
Entity Type:Individual
Prefix:
First Name:TAMIESHA
Middle Name:
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 1:14735 MARTELL AVE APT A
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-4441
Mailing Address - Country:US
Mailing Address - Phone:209-448-8740
Mailing Address - Fax:
Practice Address - Street 1:STE CONSULTANT, LLC
Practice Address - Street 2:3650 MT. DIABLO BLVD, SUITE 107
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549
Practice Address - Country:US
Practice Address - Phone:510-665-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician