Healthcare Provider Details

I. General information

NPI: 1851255764
Provider Name (Legal Business Name): TARA JACKSON CPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1274 CONGRESS ST
PORTLAND ME
04102-2111
US

IV. Provider business mailing address

1274 CONGRESS ST
PORTLAND ME
04102-2111
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-1002
  • Fax:
Mailing address:
  • Phone: 207-774-1002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO04857
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: