Provider Demographics
NPI:1851748602
Name:JACKSON, YLENCIA D (NP)
Entity Type:Individual
Prefix:
First Name:YLENCIA
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:306 MEADOWRIDGE DR
Mailing Address - Street 2:STE A
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-2128
Mailing Address - Country:US
Mailing Address - Phone:478-929-8847
Mailing Address - Fax:
Practice Address - Street 1:100 JIM MASON CT
Practice Address - Street 2:STE A
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8965
Practice Address - Country:US
Practice Address - Phone:478-474-2947
Practice Address - Fax:478-971-4004
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA147416363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner