Provider Demographics
NPI:1871316067
Name:JACKSON, TATIANA
Entity type:Individual
Prefix:
First Name:TATIANA
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 1:4209 SPRING STUEBNER RD APT 35105
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-5391
Mailing Address - Country:US
Mailing Address - Phone:281-825-9984
Mailing Address - Fax:
Practice Address - Street 1:20008 CHAMPION FOREST DR STE 601
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-8696
Practice Address - Country:US
Practice Address - Phone:281-892-9986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator