Provider Demographics
NPI:1326647199
Name:JACKSON, BREIANE (LICENSED CPHT)
Entity Type:Individual
Prefix:
First Name:BREIANE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LICENSED CPHT
Other - Prefix:
Other - First Name:BREIANE
Other - Middle Name:
Other - Last Name:HATCHETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4624 UNICORN PT
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-5374
Mailing Address - Country:US
Mailing Address - Phone:770-361-1315
Mailing Address - Fax:
Practice Address - Street 1:2790 COBB PKWY NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3455
Practice Address - Country:US
Practice Address - Phone:770-793-1838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHTC051863183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician