Provider Demographics
NPI:1255981296
Name:JACKSON, TAMMARA (DPT)
Entity type:Individual
Prefix:DR
First Name:TAMMARA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 AUTUMNHILL LN
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38135-1646
Mailing Address - Country:US
Mailing Address - Phone:901-315-5803
Mailing Address - Fax:
Practice Address - Street 1:3385 AIRWAYS BLVD STE 219
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-3808
Practice Address - Country:US
Practice Address - Phone:901-205-9534
Practice Address - Fax:833-471-4041
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS6595225100000X
225100000X
TN12169225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist