Provider Demographics
NPI:1528550209
Name:JACKSON, ATAVIA (ST)
Entity Type:Individual
Prefix:
First Name:ATAVIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5229 JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:MORVEN
Mailing Address - State:GA
Mailing Address - Zip Code:31638-3934
Mailing Address - Country:US
Mailing Address - Phone:229-561-5507
Mailing Address - Fax:
Practice Address - Street 1:5229 JACKSON RD
Practice Address - Street 2:
Practice Address - City:MORVEN
Practice Address - State:GA
Practice Address - Zip Code:31638-3934
Practice Address - Country:US
Practice Address - Phone:229-561-5507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor