Provider Demographics
NPI:1750131710
Name:JACKSON, TANGENEE N
Entity type:Individual
Prefix:
First Name:TANGENEE
Middle Name:N
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 1:5148 CALLAN DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-3773
Mailing Address - Country:US
Mailing Address - Phone:317-373-1921
Mailing Address - Fax:317-875-1408
Practice Address - Street 1:5148 CALLAN DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-3773
Practice Address - Country:US
Practice Address - Phone:317-373-1921
Practice Address - Fax:317-875-1408
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN24-016790253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care