Provider Demographics
NPI:1073904587
Name:JACKSON, YOLANDA TRENETT (PTA)
Entity Type:Individual
Prefix:
First Name:YOLANDA
Middle Name:TRENETT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 WEEMS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-3279
Mailing Address - Country:US
Mailing Address - Phone:706-905-9256
Mailing Address - Fax:
Practice Address - Street 1:400 EMBASSY ROW
Practice Address - Street 2:SUITE 125
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-1667
Practice Address - Country:US
Practice Address - Phone:770-225-8421
Practice Address - Fax:866-587-9993
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002327225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant