Provider Demographics
NPI:1366090813
Name:JACKSON, ALICE
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1389 GORDON RD
Mailing Address - Street 2:
Mailing Address - City:MORELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30259-2541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1389 GORDON RD
Practice Address - Street 2:
Practice Address - City:MORELAND
Practice Address - State:GA
Practice Address - Zip Code:30259-2541
Practice Address - Country:US
Practice Address - Phone:770-251-8209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000OtherDEPARTMENT OF VA AFFAIRS