Provider Demographics
NPI:1598140725
Name:JACKSON, CRYSTAL (LPN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1585 HOLLOWAY RAY RD
Mailing Address - Street 2:
Mailing Address - City:MC INTYRE
Mailing Address - State:GA
Mailing Address - Zip Code:31054-2469
Mailing Address - Country:US
Mailing Address - Phone:478-234-1166
Mailing Address - Fax:
Practice Address - Street 1:1585 HOLLOWAY RAY RD
Practice Address - Street 2:
Practice Address - City:MC INTYRE
Practice Address - State:GA
Practice Address - Zip Code:31054-2469
Practice Address - Country:US
Practice Address - Phone:478-234-1166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN090801164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse