Provider Demographics
NPI:1245940121
Name:JACKSON, TONTALAYAH ZURI
Entity type:Individual
Prefix:
First Name:TONTALAYAH
Middle Name:ZURI
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TONTALAYAH
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:936 HOE AVE APT 2A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-3653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:936 HOE AVE APT 2A
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-3653
Practice Address - Country:US
Practice Address - Phone:917-792-7116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344925-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse