Healthcare Provider Details

I. General information

NPI: 1336934835
Provider Name (Legal Business Name): TAMARA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8616 LA TIJERA BLVD
LOS ANGELES CA
90045-3944
US

IV. Provider business mailing address

8616 LA TIJERA BLVD
LOS ANGELES CA
90045-3944
US

V. Phone/Fax

Practice location:
  • Phone: 310-337-7827
  • Fax:
Mailing address:
  • Phone: 310-337-7827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: