Healthcare Provider Details

I. General information

NPI: 1538708268
Provider Name (Legal Business Name): TATIA PATRICE JACKSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2019
Last Update Date: 12/28/2019
Certification Date: 12/28/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3448 PINEHILL DR
DECATUR GA
30032-3031
US

IV. Provider business mailing address

3448 PINEHILL DR
DECATUR GA
30032-3031
US

V. Phone/Fax

Practice location:
  • Phone: 414-732-8636
  • Fax:
Mailing address:
  • Phone: 414-732-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: