Provider Demographics
NPI:1932466455
Name:JACKSON-PONDER, TIFFANY SHAUNTE' (PTA)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:SHAUNTE'
Last Name:JACKSON-PONDER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 N MILL ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-3577
Mailing Address - Country:US
Mailing Address - Phone:630-355-3300
Mailing Address - Fax:
Practice Address - Street 1:1136 N MILL ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-3577
Practice Address - Country:US
Practice Address - Phone:630-355-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-22
Last Update Date:2012-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005716225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant