Provider Demographics
NPI:1689473886
Name:JACKSON, TANIKA
Entity type:Individual
Prefix:
First Name:TANIKA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08629-2412
Mailing Address - Country:US
Mailing Address - Phone:609-643-1342
Mailing Address - Fax:
Practice Address - Street 1:859 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08629-2412
Practice Address - Country:US
Practice Address - Phone:609-643-1342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRBT-22-235284106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician