Provider Demographics
NPI:1538757810
Name:JACKSON, TARJILYN M (BSN,RN)
Entity type:Individual
Prefix:MS
First Name:TARJILYN
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BSN,RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2613 AVENIDO DEL PINAR ST
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-6838
Mailing Address - Country:US
Mailing Address - Phone:228-623-8312
Mailing Address - Fax:
Practice Address - Street 1:2613 AVENIDO DEL PINAR ST
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-6838
Practice Address - Country:US
Practice Address - Phone:228-623-8312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS909409163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2613OtherWORK RELATED
MS2613OtherEMPLOYEE RELATED