Provider Demographics
NPI:1538708268
Name:JACKSON, TATIA PATRICE (PHD)
Entity type:Individual
Prefix:DR
First Name:TATIA
Middle Name:PATRICE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3448 PINEHILL DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-3031
Mailing Address - Country:US
Mailing Address - Phone:414-732-8636
Mailing Address - Fax:
Practice Address - Street 1:3448 PINEHILL DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-3031
Practice Address - Country:US
Practice Address - Phone:414-732-8636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-28
Last Update Date:2019-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA372600000X, 374U00000X, 376J00000X, 372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker