Provider Demographics
NPI:1609187053
Name:RACKLEY, JEFFERSON BLAKE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERSON
Middle Name:BLAKE
Last Name:RACKLEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-2424
Mailing Address - Country:US
Mailing Address - Phone:706-680-0055
Mailing Address - Fax:
Practice Address - Street 1:63 SPRINGS STATION DR.
Practice Address - Street 2:
Practice Address - City:FRANKLIN SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30639
Practice Address - Country:US
Practice Address - Phone:706-246-0733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist