Provider Demographics
NPI:1699810788
Name:JACKSON, TANYA DIANE (RNFA)
Entity type:Individual
Prefix:MS
First Name:TANYA
Middle Name:DIANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:MS
Other - First Name:TANYA
Other - Middle Name:DIANE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RNFA
Mailing Address - Street 1:3016 LAGUNA DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79110-3149
Mailing Address - Country:US
Mailing Address - Phone:806-355-6626
Mailing Address - Fax:806-358-4899
Practice Address - Street 1:1911 PORT LN
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2470
Practice Address - Country:US
Practice Address - Phone:806-358-4839
Practice Address - Fax:806-358-4899
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX252294163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant