Provider Information for 1700395571
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TANISHA JACKSON
Sex: Female
NPI: 1700395571
Last Updated: 2017-09-25
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||||||||||
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| NPI | 1700395571 | ||||||||||||||||
| Enumeration Date | 2017-09-25 | ||||||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||||||
| Sole Proprietor | YES | ||||||||||||||||
| Status | Active | ||||||||||||||||
| Mailing Address | 9500 ANNAPOLIS RD LANHAM, MD 20706-2060 United States Phone: | Fax: | ||||||||||||||||
| Primary Practice Address | 9500 ANNAPOLIS RD A8 LANHAM, MD 20706 United States Phone: 301-710-9400 | Fax: | ||||||||||||||||
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