Provider Demographics
NPI:1386801421
Name:JACKSON, TAMEATRICE MICHELLE (RN/CRT)
Entity type:Individual
Prefix:MS
First Name:TAMEATRICE
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN/CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 CHESTNUT SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-1323
Mailing Address - Country:US
Mailing Address - Phone:904-382-1793
Mailing Address - Fax:904-253-6759
Practice Address - Street 1:2506 CHESTNUT SPRINGS LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-1323
Practice Address - Country:US
Practice Address - Phone:904-382-1793
Practice Address - Fax:904-253-6759
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9255446374T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693464196Medicaid