MEDICARE: TAWANNA JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174H00000X	Health Educator	110587	TX

General Provider Information

NPI Number	:	1619121365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAWANNA JACKSON

Provider Business Mailing Address
First Line	:	3824 CEDAR SPRINGS RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-4136
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3824 CEDAR SPRINGS RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-4136
Country	:	US
Telephone Number	:	214-555-1111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2008
Last Update Date	:	11/13/2014

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Directions to “ TAWANNA JACKSON ” Practice Location

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