Provider Demographics
NPI:1225101868
Name:JACKSON, LORNA C (DDS)
Entity Type:Individual
Prefix:DR
First Name:LORNA
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 ABERCORN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31401-7315
Mailing Address - Country:US
Mailing Address - Phone:912-233-7970
Mailing Address - Fax:
Practice Address - Street 1:106 E BROAD ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31401-2917
Practice Address - Country:US
Practice Address - Phone:912-527-1086
Practice Address - Fax:912-527-1126
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000814943AMedicaid