Healthcare Provider Details

I. General information

NPI: 1841486065
Provider Name (Legal Business Name): TENAYA JACKMAN L.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

378 BELMONT ST #4
OAKLAND CA
94610-4842
US

IV. Provider business mailing address

378 BELMONT ST #4
OAKLAND CA
94610-4842
US

V. Phone/Fax

Practice location:
  • Phone: 510-832-1648
  • Fax: 510-832-1648
Mailing address:
  • Phone: 510-832-1648
  • Fax: 510-832-1648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number212
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: