Provider Demographics
NPI:1215759097
Name:JACKSON, TANESHA
Entity type:Individual
Prefix:MRS
First Name:TANESHA
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 1:319 LANIER CT
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2072
Mailing Address - Country:US
Mailing Address - Phone:470-962-7121
Mailing Address - Fax:
Practice Address - Street 1:319 LANIER CT
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2072
Practice Address - Country:US
Practice Address - Phone:470-962-7121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care