Provider Demographics
NPI:1669180717
Name:JACKSON, TAMMY ELIZABETH (PMHNP)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 SHADRICK FERRY RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-9476
Mailing Address - Country:US
Mailing Address - Phone:502-385-0806
Mailing Address - Fax:
Practice Address - Street 1:409 HOLMES ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-2209
Practice Address - Country:US
Practice Address - Phone:502-385-0806
Practice Address - Fax:502-385-0656
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018653363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health