Healthcare Provider Details

I. General information

NPI: 1619103959
Provider Name (Legal Business Name): TISSAN TILDEN JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 HIGHWAY 80 W
JACKSON MS
39209-7201
US

IV. Provider business mailing address

3450 HIGHWAY 80 W
JACKSON MS
39209-7201
US

V. Phone/Fax

Practice location:
  • Phone: 601-321-2400
  • Fax: 601-985-5174
Mailing address:
  • Phone: 601-316-0951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC10433
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: