Provider Demographics
NPI:1083436190
Name:JACKSON, TAMERA I
Entity type:Individual
Prefix:
First Name:TAMERA
Middle Name:I
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 1:906 SEMINOLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-7648
Mailing Address - Country:US
Mailing Address - Phone:772-475-5313
Mailing Address - Fax:800-374-4167
Practice Address - Street 1:906 SEMINOLE DR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-7648
Practice Address - Country:US
Practice Address - Phone:772-475-5313
Practice Address - Fax:800-374-4167
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician