Provider Demographics
NPI:1699349357
Name:BASS-JACKSON, TIFFANY (APC)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:
Last Name:BASS-JACKSON
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90F GLENDA TRCE STE 244
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-3858
Mailing Address - Country:US
Mailing Address - Phone:706-289-9642
Mailing Address - Fax:762-333-2872
Practice Address - Street 1:90F GLENDA TRCE STE 244
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-3858
Practice Address - Country:US
Practice Address - Phone:706-289-9642
Practice Address - Fax:678-578-5830
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012222101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional