Provider Demographics
NPI:1720255094
Name:JACKSON, TAMIKA ELISE
Entity Type:Individual
Prefix:MISS
First Name:TAMIKA
Middle Name:ELISE
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 1:626 E WOODLAND PARK AVE
Mailing Address - Street 2:APT 307
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4155
Mailing Address - Country:US
Mailing Address - Phone:312-731-6060
Mailing Address - Fax:
Practice Address - Street 1:626 E WOODLAND PARK AVE
Practice Address - Street 2:APT 307
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4155
Practice Address - Country:US
Practice Address - Phone:312-731-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist