Provider Demographics
NPI:1851654248
Name:JACKSON, TASHA ANN (LCSW)
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2939
Mailing Address - Country:US
Mailing Address - Phone:850-872-7760
Mailing Address - Fax:
Practice Address - Street 1:210 E 11TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2939
Practice Address - Country:US
Practice Address - Phone:850-872-7760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health