Provider Demographics
NPI:1992046734
Name:JACKSON, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4746 WALFORD RD APT 2
Mailing Address - Street 2:
Mailing Address - City:WARRENSVILLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5151
Mailing Address - Country:US
Mailing Address - Phone:216-210-0536
Mailing Address - Fax:
Practice Address - Street 1:4746 WALFORD RD APT 2
Practice Address - Street 2:
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44128-5151
Practice Address - Country:US
Practice Address - Phone:216-210-0536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH151542164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse