Active NPI
Tiffany Jackson
- Registered Nurse
- Southaven, MS
National Provider Identifier
1124762794
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Nurse
- License
- 917293
- Practice address
- 5875 Landau Dr
Southaven, MS 38671-8946 - Phone
- (870) 821-1234
- NPI assigned
- Apr 20, 2022
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Nurse | 163W00000X | 917293 | MS | Primary |
Addresses
Primary practice location
5875 Landau Dr
Southaven, MS 38671-8946
Mailing address
5875 Landau Dr
Southaven, MS 38671-8946
Phone (870) 821-1234
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IN
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
Enrollment records 1
Care Compare profile
Medicare Care Compare- Specialty
- Nurse Practitioner
- Education
- Other, 2024
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
Practice addresses (Care Compare)
429 E Vermont St
Suite 110
Indianapolis, IN 46202-3685
Phone (317) 559-0950
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 917293 | MS | MD | Registered Nurse |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| My Mobile MD Psychiatric Services LLC | Current | Accepting new patients |
Locations
429 E Vermont St
Ste 110
Indianapolis, IN 46202
Phone (317) 536-2290
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Psychiatry Physician
- Indianapolis, IN
- NPI 1528712452
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1650412800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1650412800000",
"number": "1124762794",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5875 LANDAU DR",
"city": "SOUTHAVEN",
"state": "MS",
"postal_code": "386718946",
"telephone_number": "870-821-1234"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5875 LANDAU DR",
"city": "SOUTHAVEN",
"state": "MS",
"postal_code": "386718946",
"telephone_number": "870-821-1234"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "TIFFANY",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2022-04-20",
"last_updated": "2022-04-20",
"certification_date": "2022-04-20",
"status": "A"
},
"taxonomies": [
{
"code": "163W00000X",
"taxonomy_group": "",
"desc": "Registered Nurse",
"state": "MS",
"license": "917293",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Southaven, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 20, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.