Healthcare Provider Details

I. General information

NPI: 1124762794
Provider Name (Legal Business Name): TIFFANY JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5875 LANDAU DR
SOUTHAVEN MS
38671-8946
US

IV. Provider business mailing address

5875 LANDAU DR
SOUTHAVEN MS
38671-8946
US

V. Phone/Fax

Practice location:
  • Phone: 870-821-1234
  • Fax:
Mailing address:
  • Phone: 870-821-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71016838A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: