Provider Demographics
NPI:1174890057
Name:JACKSON, TANESHA (RN)
Entity type:Individual
Prefix:MISS
First Name:TANESHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N PLUMER AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-5906
Mailing Address - Country:US
Mailing Address - Phone:520-225-3284
Mailing Address - Fax:
Practice Address - Street 1:1010 E 10TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-5813
Practice Address - Country:US
Practice Address - Phone:520-225-3284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN154502163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse