Provider Demographics
NPI:1184169997
Name:JACKSON, AUBREY
Entity type:Individual
Prefix:
First Name:AUBREY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 N HILLBROOKE TRCE
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30005-7238
Mailing Address - Country:US
Mailing Address - Phone:404-427-3457
Mailing Address - Fax:
Practice Address - Street 1:5405 N HILLBROOKE TRCE
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30005-7238
Practice Address - Country:US
Practice Address - Phone:404-427-3457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)