Basic Information
| Provider Information | |||||||||
| NPI: | 1942874193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | TONYA | ||||||||
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| Credential: | MT-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 146 RAMSEY CIR | ||||||||
| Address2: | |||||||||
| City: | RUSTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712701693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105484120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E WOODROW WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2021 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225A00000X | 06219 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Music Therapist |
ID Information
| ID | Type | State | Issuer | Description | 06219 | 01 | WI | CBMT | OTHER |