Basic Information
| Provider Information | |||||||||
| NPI: | 1194480962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | TYESHA | ||||||||
| MiddleName: | BROOKES | ||||||||
| NamePrefix: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROOKES | ||||||||
| OtherFirstName: | TYESHA | ||||||||
| OtherMiddleName: | JACINDA | ||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 KIMEL FOREST DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367161331 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 905 PHILLIPS AVE | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3680220403 | ||||||||
| FaxNumber: | 3368022041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2021 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5015370 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 5015370 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.