Provider Demographics
NPI:1942491063
Name:JACKSON, TIFFANY R (MD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7217 TELECOM PARKWAY
Mailing Address - Street 2:SUITE 290
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044
Mailing Address - Country:US
Mailing Address - Phone:469-800-2240
Mailing Address - Fax:469-800-2251
Practice Address - Street 1:7217 TELECOM PARKWAY
Practice Address - Street 2:SUITE 290
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75044
Practice Address - Country:US
Practice Address - Phone:469-800-2240
Practice Address - Fax:469-800-2251
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109226207V00000X
TXP5385207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3264939-01Medicaid
TX3264939-01Medicaid