Provider Demographics
NPI:1851683460
Name:JACKSON, VENITA JOY (PA-C)
Entity Type:Individual
Prefix:
First Name:VENITA
Middle Name:JOY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VENITA
Other - Middle Name:JOY
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:550 PEACHTREE ST NE
Mailing Address - Street 2:1810
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:1810
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2208
Practice Address - Country:US
Practice Address - Phone:404-223-1329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-15
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006087363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical