Provider Demographics
NPI:1770017949
Name:JACKSON, AMANDA (ATC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WETHERSFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-4965
Mailing Address - Country:US
Mailing Address - Phone:919-370-0423
Mailing Address - Fax:
Practice Address - Street 1:1269 BARCLAY CIR SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2903
Practice Address - Country:US
Practice Address - Phone:919-370-0423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0030822255A2300X
NCLAT-28192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer