Provider Demographics
NPI:1740505783
Name:JACSON, TANEISHA (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:TANEISHA
Middle Name:
Last Name:JACSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5023 36TH PL
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-3909
Mailing Address - Country:US
Mailing Address - Phone:240-441-8441
Mailing Address - Fax:
Practice Address - Street 1:4660 MARTIN LUTHER KING JR AVE SW STE A3
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4958
Practice Address - Country:US
Practice Address - Phone:202-558-4681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1003671363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily