MEDICARE: MRS. TONDA P JACKSON FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APN883	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184690174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TONDA P JACKSON FNP

Provider Business Mailing Address
First Line	:	6255 W SUNSET BLVD FL 21
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-7422
Country	:	US
Telephone Number	:	323-860-5200
Fax Number	:	323-467-7119

Provider Business Practice Location Address
First Line	:	4100 N MAIN ST STE 102
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-5800
Country	:	US
Telephone Number	:	803-223-9895
Fax Number	:	803-735-3641

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2006
Last Update Date	:	05/06/2024

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