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NPI Code Detail

MEDICARE: TANA JACKSON-WILSON

MEDICARE: TANA JACKSON-WILSON
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
1164W00000XLicensed Practical NurseLP048815AZ
2164W00000XLicensed Practical Nurse043114639IL

General Provider Information

NPI Number : 1639504152
Entity Type Code : Individual
Provider Name (Legal Business Name) : TANA JACKSON-WILSON
Provider Business Mailing Address
First Line : 4612 N 28TH ST
Second Line : CAMELBACK HS MEDICALLY FRAGILE
City : PHOENIX
State : AZ
Zip : 85016-4931
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4612 N 28TH ST
Second Line : CAMELBACK HS MEDICALLY FRAGILE
City : PHOENIX
State : AZ
Zip : 85016-4931
Country : US
Telephone Number : 602-764-7122
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/04/2013
Last Update Date : 09/04/2013

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Directions to “ TANA JACKSON-WILSON ” Practice Location

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