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General NPI Number Information
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NPI Number | 1538708268
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Entity Type | Individual
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Provider Name | TATIA PATRICE JACKSON PHD
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Gender | Female
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Dates
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Enumeration Date | 12/28/2019
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Last Update Date | 12/28/2019
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Provider Practice Location Address
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Address Line | 3448 PINEHILL DR
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City | DECATUR
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State | GA
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Zip | 30032-3031
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Country | US
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Telephone | 414-732-8636
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Fax |
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Provider Business Mailing Address
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Address Line | 3448 PINEHILL DR
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City | DECATUR
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State | GA
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Zip | 30032-3031
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Country | US
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Telephone | 414-732-8636
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 372600000X
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Taxonomy Name | Adult Companion
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License Number |
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number |
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 376J00000X
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Taxonomy Name | Homemaker
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License Number |
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 372500000X
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Taxonomy Name | Chore Provider
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License Number |
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License Number State | GA
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