Provider Demographics
NPI:1770072332
Name:JACKSON, TARA NAOMI (DO)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:NAOMI
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-4221
Mailing Address - Country:US
Mailing Address - Phone:417-255-8464
Mailing Address - Fax:405-231-3037
Practice Address - Street 1:1137 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-4221
Practice Address - Country:US
Practice Address - Phone:417-255-8464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021028685207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine