Provider Demographics
NPI:1639251069
Name:JACKSON, JENNIFER W (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 GORDON ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30673-1604
Mailing Address - Country:US
Mailing Address - Phone:706-678-2622
Mailing Address - Fax:706-678-3115
Practice Address - Street 1:204 GORDON ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:GA
Practice Address - Zip Code:30673-1604
Practice Address - Country:US
Practice Address - Phone:706-678-2622
Practice Address - Fax:706-678-3115
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN141785163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator