Provider Demographics
NPI:1366882714
Name:JACKSON, TAMARA M
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:M
Other - Last Name:GARVEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1240 SW 171ST TER
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1435
Mailing Address - Country:US
Mailing Address - Phone:954-812-7255
Mailing Address - Fax:
Practice Address - Street 1:53 ASH DR
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33026-1102
Practice Address - Country:US
Practice Address - Phone:954-579-6131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-30
Last Update Date:2013-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ5869235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist