1053994079 NPI number — TIFFANY ANN JACKSON LPC

Table of content: TIFFANY ANN JACKSON LPC (NPI 1053994079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053994079 NPI number — TIFFANY ANN JACKSON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
TIFFANY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HENDERSON
Provider Other First Name:
TIFFANY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053994079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4219 ORANGE GROVE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77039-6313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-470-5888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2004 TRUMAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77327-4745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-432-3000
Provider Business Practice Location Address Fax Number:
936-760-2898
Provider Enumeration Date:
04/29/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  86357 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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