=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114678257
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TENA MARIA JACKSON FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2022
-----------------------------------------------------
Last Update Date | 10/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 N STYGLER RD # 3410
-----------------------------------------------------
City | GAHANNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43230-2435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-389-2727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 TOWN CENTER LOOP
-----------------------------------------------------
City | PATASKALA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43062-7697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-794-1919
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | APRN11017532
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11017532
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0037595
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 2021117108
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | APRN.CNP.0037595
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------