Provider Demographics
NPI:1356167217
Name:JACKSON, TINISHIA RENEE
Entity type:Individual
Prefix:
First Name:TINISHIA
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39180 LIBERTY ST SUITE 205
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538
Mailing Address - Country:US
Mailing Address - Phone:510-439-0657
Mailing Address - Fax:510-439-0658
Practice Address - Street 1:39180 LIBERTY ST SUITE 205
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538
Practice Address - Country:US
Practice Address - Phone:510-439-0657
Practice Address - Fax:510-439-0658
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician