Provider Demographics
NPI:1336342559
Name:JACKSON, TWANNA EVETTE (APN, BC)
Entity Type:Individual
Prefix:MRS
First Name:TWANNA
Middle Name:EVETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38126-5017
Mailing Address - Country:US
Mailing Address - Phone:901-593-2530
Mailing Address - Fax:855-575-2324
Practice Address - Street 1:855 S 4TH ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38126-5017
Practice Address - Country:US
Practice Address - Phone:901-593-2530
Practice Address - Fax:833-575-2324
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12795363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily