Provider Demographics
NPI:1861049272
Name:GATES-JACKSON, TAMRA VENESHA (PTA)
Entity type:Individual
Prefix:
First Name:TAMRA
Middle Name:VENESHA
Last Name:GATES-JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1359 W 90TH AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6750
Mailing Address - Country:US
Mailing Address - Phone:219-588-7238
Mailing Address - Fax:
Practice Address - Street 1:101 W 87TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6177
Practice Address - Country:US
Practice Address - Phone:219-756-0744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002957A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant