Provider Demographics
NPI:1093879769
Name:JACKSON, SOPHIA EVETTE (NP)
Entity Type:Individual
Prefix:MRS
First Name:SOPHIA
Middle Name:EVETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4249 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-9008
Mailing Address - Country:US
Mailing Address - Phone:770-292-8634
Mailing Address - Fax:770-965-2269
Practice Address - Street 1:1950 BUFORD HWY
Practice Address - Street 2:CVS CAREMARK MINUTE CLINIC
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-3673
Practice Address - Country:US
Practice Address - Phone:770-945-7286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN117221363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00792426CMedicaid
GAS56481Medicare UPIN