Provider Demographics
NPI:1346633229
Name:JACKSON, CASSONDRA (APC)
Entity Type:Individual
Prefix:MS
First Name:CASSONDRA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 HAWTHORN LN
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-4208
Mailing Address - Country:US
Mailing Address - Phone:678-492-9332
Mailing Address - Fax:
Practice Address - Street 1:1076 HAWTHORN LN
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-4208
Practice Address - Country:US
Practice Address - Phone:678-492-9332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC004749101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health