MEDICARE: TANIESHA M 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	235Z00000X	Speech-Language Pathologist	SP8464	OH

General Provider Information

NPI Number	:	1790909653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANIESHA M JACKSON

Provider Business Mailing Address
First Line	:	2914 CAMBRIDGE CIR
Second Line	:
City	:	WICKLIFFE
State	:	OH
Zip	:	44092-3018
Country	:	US
Telephone Number	:	440-585-7661
Fax Number	:

Provider Business Practice Location Address
First Line	:	1835 BELMORE RD
Second Line	:
City	:	EAST CLEVELAND
State	:	OH
Zip	:	44112-4301
Country	:	US
Telephone Number	:	216-268-3600
Fax Number	:	216-851-7363

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	07/08/2007

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