Provider Demographics
NPI:1477754398
Name:JACKSON, JENNIFER MARIE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 CRIMSON OAK DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-8179
Mailing Address - Country:US
Mailing Address - Phone:706-231-7361
Mailing Address - Fax:
Practice Address - Street 1:544 S 400 E
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3705
Practice Address - Country:US
Practice Address - Phone:435-688-5494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist