Provider Demographics
NPI:1750717179
Name:JACKSON LUCKEY, TAMIQUA (FNP-C, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TAMIQUA
Middle Name:
Last Name:JACKSON LUCKEY
Suffix:
Gender:F
Credentials:FNP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8406 SIX FORKS RD STE 104
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3075
Mailing Address - Country:US
Mailing Address - Phone:919-642-4857
Mailing Address - Fax:855-484-7483
Practice Address - Street 1:8406 SIX FORKS RD STE 104
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3075
Practice Address - Country:US
Practice Address - Phone:919-642-4857
Practice Address - Fax:855-484-7483
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006558363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily