Provider Demographics
NPI:1891054268
Name:JACKSON, CARRIE B (RN, BSN, MBA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, BSN, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CLOUD FOREST CT
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-1451
Mailing Address - Country:US
Mailing Address - Phone:770-377-4834
Mailing Address - Fax:404-393-7767
Practice Address - Street 1:157 BURKE ST STE 119
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-3444
Practice Address - Country:US
Practice Address - Phone:678-249-9311
Practice Address - Fax:404-393-7767
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN070257163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse