Provider Demographics
NPI:1417531948
Name:JACKSON, TAYSHA N
Entity type:Individual
Prefix:
First Name:TAYSHA
Middle Name:N
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 1:2211 TUCKER LN # LANE4
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-7260
Mailing Address - Country:US
Mailing Address - Phone:443-759-2787
Mailing Address - Fax:
Practice Address - Street 1:500 REDLAND CT STE 102
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3265
Practice Address - Country:US
Practice Address - Phone:443-738-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician