Provider Demographics
NPI:1649228172
Name:JACKSON, VANNA MANIGAULT (MD FAAP)
Entity Type:Individual
Prefix:
First Name:VANNA
Middle Name:MANIGAULT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:993 F JOHNSON FERRY RD
Mailing Address - Street 2:STE 370
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-252-4611
Mailing Address - Fax:404-256-1759
Practice Address - Street 1:993 F JOHNSON FERRY RD
Practice Address - Street 2:STE 370
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-252-4611
Practice Address - Fax:404-256-1759
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043420208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics