Provider Demographics
NPI:1023712726
Name:JACKSON, TAMARA DOMINIQUE
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:DOMINIQUE
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 1:1367 MASSACHUSETTS AVE SE # 2
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-1540
Mailing Address - Country:US
Mailing Address - Phone:202-977-1259
Mailing Address - Fax:
Practice Address - Street 1:2218 RHODE ISLAND AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2827
Practice Address - Country:US
Practice Address - Phone:202-717-9428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC1023712726172V00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker