Healthcare Provider Details

I. General information

NPI: 1811808868
Provider Name (Legal Business Name): TIANA LEE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 POPLAR ST
BRIDGETON NJ
08302-6656
US

IV. Provider business mailing address

585 POPLAR ST
BRIDGETON NJ
08302-6656
US

V. Phone/Fax

Practice location:
  • Phone: 609-364-8237
  • Fax:
Mailing address:
  • Phone: 609-364-8237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: