Provider Demographics
NPI:1124728878
Name:JACKSON, TENEISHA LASHAUN
Entity type:Individual
Prefix:
First Name:TENEISHA
Middle Name:LASHAUN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TENEISHA
Other - Middle Name:LASHAUN
Other - Last Name:MCKINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27 LONGLEAF CIR
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:NC
Mailing Address - Zip Code:28326-9055
Mailing Address - Country:US
Mailing Address - Phone:910-651-5057
Mailing Address - Fax:
Practice Address - Street 1:27 LONGLEAF CIR
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:NC
Practice Address - Zip Code:28326-9055
Practice Address - Country:US
Practice Address - Phone:910-651-5057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician