Provider Demographics
NPI:1407236045
Name:JACKSON-WEATHERS, PATRICE M (CNA)
Entity Type:Individual
Prefix:MRS
First Name:PATRICE
Middle Name:M
Last Name:JACKSON-WEATHERS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 WILLOW RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-1284
Mailing Address - Country:US
Mailing Address - Phone:470-829-1973
Mailing Address - Fax:
Practice Address - Street 1:4266 LINDSEY DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-1927
Practice Address - Country:US
Practice Address - Phone:470-965-3741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI344541376K00000X
SC560249376K00000X
GACN0014212008376K00000X
376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No376G00000XNursing Service Related ProvidersNursing Home Administrator