Healthcare Provider Details

I. General information

NPI: 1093169823
Provider Name (Legal Business Name): TARA JACKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 G CORUM LN
AUBURN KY
42206-5000
US

IV. Provider business mailing address

104 G CORUM LN
AUBURN KY
42206-5000
US

V. Phone/Fax

Practice location:
  • Phone: 270-847-7004
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: TARA JACKSON
Title or Position: DEVELOPMENTAL INTERVENTIONIST
Credential:
Phone: 270-847-7004