Provider Demographics
NPI:1558876524
Name:JACKSON, SAVANNAH BRYANNA (NP)
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:BRYANNA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PROFESSIONAL PARK
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 PROFESSIONAL PL STE 204
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3802
Practice Address - Country:US
Practice Address - Phone:770-834-3351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN222275363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care