Provider Demographics
NPI:1811229396
Name:JACKSON, SARAH ELLIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:ELLIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WHITEHEAD RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-1554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 WHITEHEAD RD
Practice Address - Street 2:SUITE 3
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-1554
Practice Address - Country:US
Practice Address - Phone:706-369-3856
Practice Address - Fax:706-369-3811
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005839101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional