Provider Demographics
NPI:1053968412
Name:JACKSON, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 E DUBLIN GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-3192
Mailing Address - Country:US
Mailing Address - Phone:614-844-3800
Mailing Address - Fax:
Practice Address - Street 1:7529 WARREN SHARON RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:OH
Practice Address - Zip Code:44403-9796
Practice Address - Country:US
Practice Address - Phone:740-415-1138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician