Healthcare Provider Details

I. General information

NPI: 1851613251
Provider Name (Legal Business Name): TIFFANY RENEE JACKSON M.S.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5533 LITCHFIELD ST
PHILADELPHIA PA
19143-4714
US

IV. Provider business mailing address

5533 LITCHFIELD ST
PHILADELPHIA PA
19143-4714
US

V. Phone/Fax

Practice location:
  • Phone: 267-320-8598
  • Fax:
Mailing address:
  • Phone: 267-320-8598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number171W00000X
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: