Provider Demographics
NPI:1205070208
Name:JACKSON, TYSHALL SHAMICK (RN)
Entity type:Individual
Prefix:MRS
First Name:TYSHALL
Middle Name:SHAMICK
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:TYSHALL
Other - Middle Name:SHAMICK
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:5308 HALPIN AVE
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-1132
Mailing Address - Country:US
Mailing Address - Phone:856-397-7626
Mailing Address - Fax:
Practice Address - Street 1:900 DUDLEY AVE
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-4426
Practice Address - Country:US
Practice Address - Phone:856-541-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR10973200163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse