Individual
TIERRA LEANNE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
TATTOO LICENSE
Contact information
Practice address
3322 S CAMPBELL AVE # X, SPRINGFIELD, MO 65807-4980
(417) 771-5540
Mailing address
3322 S CAMPBELL AVE # X, SPRINGFIELD, MO 65807-4980
(417) 771-5540
Taxonomy
Speciality
Code
Description
License number
State
225400000X
Rehabilitation Practitioner
Primary
2021043963
MO
247200000X
Other Technician
2021043963
MO
Other
Enumeration date
11/20/2024
Last updated
11/20/2024
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