Provider Demographics
NPI:1063879849
Name:JACKSON, TAMMIE
Entity type:Individual
Prefix:
First Name:TAMMIE
Middle Name:
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 1:1624 FRESNO ST APT 25
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-7050
Mailing Address - Country:US
Mailing Address - Phone:479-632-1116
Mailing Address - Fax:
Practice Address - Street 1:4171 N CROSSOVER RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4591
Practice Address - Country:US
Practice Address - Phone:479-521-1427
Practice Address - Fax:479-521-6520
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator