Basic Information
| Provider Information | |||||||||
| NPI: | 1780253229 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEEDHAM-JACKSON | ||||||||
| FirstName: | TISHARIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5665 PEACHTREE DUNWOODY RD | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421764 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1412 MILSTEAD AVE NE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300123877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046052800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2021 | ||||||||
| LastUpdateDate: | 06/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | RN234785 | GA | N | Nursing Service Providers | Registered Nurse | Emergency | 363L00000X | RN234785 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.