Provider Demographics
NPI:1184690174
Name:JACKSON, TONDA P (FNP)
Entity type:Individual
Prefix:MRS
First Name:TONDA
Middle Name:P
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:TONDA
Other - Middle Name:P
Other - Last Name:PRIOLEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:6255 W SUNSET BLVD FL 21
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7422
Mailing Address - Country:US
Mailing Address - Phone:323-860-5200
Mailing Address - Fax:323-467-7119
Practice Address - Street 1:4100 N MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-5800
Practice Address - Country:US
Practice Address - Phone:803-223-9895
Practice Address - Fax:803-735-3641
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN883363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0831Medicaid
SCS492492603Medicare PIN
S49249Medicare UPIN
S492492603Medicare ID - Type Unspecified