Provider Demographics
NPI:1629220017
Name:JACKSON, HEATHER M (AA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6605 ABERCORN ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5815
Mailing Address - Country:US
Mailing Address - Phone:912-354-5357
Mailing Address - Fax:
Practice Address - Street 1:11705 MERCY BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1711
Practice Address - Country:US
Practice Address - Phone:912-819-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005442367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005442OtherPA LICENSES