Healthcare Provider Details

I. General information

NPI: 1699686444
Provider Name (Legal Business Name): TIERA S JACKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2026
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 MAPLE AVE APT 2
ELIZABETH NJ
07202-2608
US

IV. Provider business mailing address

622 MAPLE AVE APT 2
ELIZABETH NJ
07202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 732-430-9605
  • Fax:
Mailing address:
  • Phone: 732-430-9605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL07471600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: