Provider Demographics
NPI:1689828899
Name:JACKSON, THIHA CADET (PA-A)
Entity Type:Individual
Prefix:MRS
First Name:THIHA
Middle Name:CADET
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-A
Other - Prefix:MS
Other - First Name:THIHA
Other - Middle Name:N
Other - Last Name:CADET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-A
Mailing Address - Street 1:531 ROSELANE STREET NW
Mailing Address - Street 2:SUITE 750
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060
Mailing Address - Country:US
Mailing Address - Phone:770-794-0477
Mailing Address - Fax:770-794-3108
Practice Address - Street 1:677 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1101
Practice Address - Country:US
Practice Address - Phone:770-794-0477
Practice Address - Fax:770-794-3108
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2023-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005476367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I320244Medicare UPIN