Provider Demographics
NPI:1477036796
Name:JACKSON, TIFFANY R (LVN)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 CALLE SECOYA ST.
Mailing Address - Street 2:APT. A
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502
Mailing Address - Country:US
Mailing Address - Phone:254-654-0502
Mailing Address - Fax:
Practice Address - Street 1:990 MARLANDWOOD RD
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-3365
Practice Address - Country:US
Practice Address - Phone:254-773-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX213654164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse