Provider Demographics
NPI:1811770910
Name:TARAVINE, JACKSON
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:TARAVINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 S ALMA SCHOOL RD STE 354
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3028
Mailing Address - Country:US
Mailing Address - Phone:480-726-2287
Mailing Address - Fax:888-503-3312
Practice Address - Street 1:14239 W BELL RD STE 108
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2470
Practice Address - Country:US
Practice Address - Phone:623-248-4283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ70349500001332B00000X
AZ7047150001332B00000X
AZ7209350001332B00000X
AZ7939960001332B00000X
AZ704516001332B00000X
AZ7046960001332B00000X
AZ8220410001332B00000X
AZ7629170001332B00000X
AZ7057360001332B00000X
AZ10227363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies