Provider Demographics
NPI:1518651785
Name:JACKSON, TAMMY DENISE
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:DENISE
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 1:301 BEAR PAW LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7071
Mailing Address - Country:US
Mailing Address - Phone:843-367-2893
Mailing Address - Fax:
Practice Address - Street 1:301 BEAR PAW LN
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-7071
Practice Address - Country:US
Practice Address - Phone:843-367-2893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider