Provider Demographics
NPI:1043012420
Name:JACKSON, TORI SHAY
Entity type:Individual
Prefix:MRS
First Name:TORI
Middle Name:SHAY
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 TRACE BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:BARBOURVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40906-7403
Mailing Address - Country:US
Mailing Address - Phone:606-595-0523
Mailing Address - Fax:
Practice Address - Street 1:335 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-1445
Practice Address - Country:US
Practice Address - Phone:606-545-7083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program