Provider Demographics
NPI:1629140462
Name:JACKSON, CEDERIC PHILLAUDER (RN MSN)
Entity Type:Individual
Prefix:MR
First Name:CEDERIC
Middle Name:PHILLAUDER
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RN MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 JESSE HILL JR DRIVE SE
Mailing Address - Street 2:ROOM 402
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303
Mailing Address - Country:US
Mailing Address - Phone:404-730-1418
Mailing Address - Fax:
Practice Address - Street 1:99 JESSIE HILL JR DRIVE
Practice Address - Street 2:
Practice Address - City:ATL
Practice Address - State:GA
Practice Address - Zip Code:30303
Practice Address - Country:US
Practice Address - Phone:404-730-1418
Practice Address - Fax:404-730-1499
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN066374163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse