Provider Demographics
NPI:1851983324
Name:JACKSON, MANEKIA K
Entity Type:Individual
Prefix:MRS
First Name:MANEKIA
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 CREEKSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-5532
Mailing Address - Country:US
Mailing Address - Phone:404-963-6148
Mailing Address - Fax:
Practice Address - Street 1:210 CREEKSIDE CIR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30168-5532
Practice Address - Country:US
Practice Address - Phone:404-906-3404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-06
Last Update Date:2021-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20094362376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker