Provider Demographics
NPI:1588274765
Name:JACKSON, TOMEKA NICHOLE (FNP-C)
Entity type:Individual
Prefix:
First Name:TOMEKA
Middle Name:NICHOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 DUTCH VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-8718
Mailing Address - Country:US
Mailing Address - Phone:803-767-0808
Mailing Address - Fax:
Practice Address - Street 1:6156 SAINT ANDREWS RD STE 208
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-3147
Practice Address - Country:US
Practice Address - Phone:803-667-9012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22632363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily