Provider Demographics
NPI:1528313558
Name:JACKSON, TATIANIE ALICIA (MD)
Entity type:Individual
Prefix:DR
First Name:TATIANIE
Middle Name:ALICIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:MC CA410
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:175-318-0447
Practice Address - Fax:717-531-5596
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA278083207U00000X, 2085R0202X
PAMD4708542085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty