Provider Demographics
NPI:1306600416
Name:JACKSON, TAMARA L (LMSW)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42586 W MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-9317
Mailing Address - Country:US
Mailing Address - Phone:480-200-4929
Mailing Address - Fax:
Practice Address - Street 1:1250 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85288-1697
Practice Address - Country:US
Practice Address - Phone:480-200-4929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-21664101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty