Provider Demographics
NPI:1366267627
Name:JACKSON, TIERRA LEANNE (TATTOO LICENSE)
Entity type:Individual
Prefix:
First Name:TIERRA
Middle Name:LEANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:TATTOO LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 S CAMPBELL AVE # X
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-4980
Mailing Address - Country:US
Mailing Address - Phone:417-771-5540
Mailing Address - Fax:
Practice Address - Street 1:3322 S CAMPBELL AVE # X
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-4980
Practice Address - Country:US
Practice Address - Phone:417-771-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021043963225400000X, 247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other