Provider Demographics
NPI:1881487841
Name:JACKSON, TYNA CARSHELLA (BSN)
Entity type:Individual
Prefix:
First Name:TYNA
Middle Name:CARSHELLA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10106 STRONECREST TRL
Mailing Address - Street 2:
Mailing Address - City:STONECREST
Mailing Address - State:GA
Mailing Address - Zip Code:30038
Mailing Address - Country:US
Mailing Address - Phone:706-877-4979
Mailing Address - Fax:
Practice Address - Street 1:10106 STRONECREST TRL
Practice Address - Street 2:
Practice Address - City:STONECREST
Practice Address - State:GA
Practice Address - Zip Code:30038
Practice Address - Country:US
Practice Address - Phone:706-877-4979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN300323163WM0705X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-SurgicalGroup - Multi-Specialty