Provider Demographics
NPI:1437360716
Name:JACKSON, GLENDA S (RN C)
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1741 CEDAR WALK LN
Mailing Address - Street 2:
Mailing Address - City:CONLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30288-1745
Mailing Address - Country:US
Mailing Address - Phone:404-361-0853
Mailing Address - Fax:404-464-0475
Practice Address - Street 1:1701 HARDEE AVE
Practice Address - Street 2:
Practice Address - City:FORT MCPHERSON
Practice Address - State:GA
Practice Address - Zip Code:30330
Practice Address - Country:US
Practice Address - Phone:404-464-0266
Practice Address - Fax:404-464-0475
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN083685163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care