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General NPI Number Information
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NPI Number | 1780253229
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Entity Type | Individual
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Provider Name | TISHARIE NEEDHAM-JACKSON NP
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Gender | Female
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Dates
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Enumeration Date | 06/19/2021
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Last Update Date | 06/22/2022
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Provider Practice Location Address
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Address Line | 1412 MILSTEAD AVE NE
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City | CONYERS
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State | GA
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Zip | 30012-3877
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Country | US
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Telephone | 404-605-2800
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Fax |
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Provider Business Mailing Address
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Address Line | 5665 PEACHTREE DUNWOODY RD
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City | ATLANTA
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State | GA
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Zip | 30342-1764
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Country | US
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Telephone |
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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 | 163WE0003X
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Taxonomy Name | Emergency Registered Nurse
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License Number | RN234785
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | RN234785
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License Number State | GA
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