Provider Demographics
NPI:1992517031
Name:JACKMAN, TANESHA T
Entity type:Individual
Prefix:
First Name:TANESHA
Middle Name:T
Last Name:JACKMAN
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 1:11 PARKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-1306
Mailing Address - Country:US
Mailing Address - Phone:347-227-5287
Mailing Address - Fax:
Practice Address - Street 1:11 PARKSIDE CT
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-1306
Practice Address - Country:US
Practice Address - Phone:347-227-5287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004034103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst