Provider Demographics
NPI:1205132206
Name:JACKSON, TANYA LYNN (FNP-BC)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HOSPITAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-1649
Mailing Address - Country:US
Mailing Address - Phone:731-352-7907
Mailing Address - Fax:731-352-4459
Practice Address - Street 1:105 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:GLEASON
Practice Address - State:TN
Practice Address - Zip Code:38229-7264
Practice Address - Country:US
Practice Address - Phone:731-648-5634
Practice Address - Fax:731-648-9155
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15540363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3380640OtherMEDICARE GROUP
TN3380640OtherMEDICAID GROUP