Provider Demographics
NPI:1891583258
Name:JACKSON, TANYA TAMARA (APRN)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:TAMARA
Last Name:JACKSON
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:968 BROOKMERE CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-6866
Mailing Address - Country:US
Mailing Address - Phone:470-633-0313
Mailing Address - Fax:
Practice Address - Street 1:968 BROOKMERE CT
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-6866
Practice Address - Country:US
Practice Address - Phone:470-633-0313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR242369363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health