Provider Demographics
NPI:1174570444
Name:JACKSON, LANA JEAN (PA)
Entity type:Individual
Prefix:
First Name:LANA
Middle Name:JEAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5670 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1704
Mailing Address - Country:US
Mailing Address - Phone:404-255-1930
Mailing Address - Fax:404-459-8510
Practice Address - Street 1:5670 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 1000
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1704
Practice Address - Country:US
Practice Address - Phone:404-255-1930
Practice Address - Fax:404-459-8510
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA003091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP54421Medicare UPIN
GA97WCGLWMedicare ID - Type Unspecified