Provider Demographics
NPI:1043933641
Name:JACKSON, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
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 1:6474 SAVANNAH HWY
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:GA
Mailing Address - Zip Code:30467-9315
Mailing Address - Country:US
Mailing Address - Phone:912-425-2479
Mailing Address - Fax:
Practice Address - Street 1:6474 SAVANNAH HWY
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:GA
Practice Address - Zip Code:30467-9315
Practice Address - Country:US
Practice Address - Phone:912-425-2479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider