Provider Demographics
NPI:1003470311
Name:JACKSON, NICOLA NATASHA (MBBS)
Entity Type:Individual
Prefix:MS
First Name:NICOLA
Middle Name:NATASHA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 PRINCE AVENUE
Mailing Address - Street 2:#70
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:706-475-7055
Mailing Address - Fax:
Practice Address - Street 1:1270 PRINCE AVENUE
Practice Address - Street 2:SUITE 201
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-475-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-12-27
Deactivation Date:2019-12-04
Deactivation Code:
Reactivation Date:2019-12-27
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program