Provider Demographics
NPI:1033471669
Name:JACKSON, VINCENT PAUL (RT(R))
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:PAUL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 GLAZE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30360-1702
Mailing Address - Country:US
Mailing Address - Phone:770-990-6821
Mailing Address - Fax:
Practice Address - Street 1:4950 GLAZE DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30360-1702
Practice Address - Country:US
Practice Address - Phone:770-990-6821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN394412247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist