Provider Demographics
NPI:1720706799
Name:JACKSON, TEQUILLA MARIE (BA)
Entity Type:Individual
Prefix:MS
First Name:TEQUILLA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:152 HIGHWAY 7 S
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5392
Mailing Address - Country:US
Mailing Address - Phone:662-234-7521
Mailing Address - Fax:662-236-3071
Practice Address - Street 1:2890 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5347
Practice Address - Country:US
Practice Address - Phone:662-234-7521
Practice Address - Fax:662-236-3071
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker