Provider Demographics
NPI:1922605690
Name:JACKSON, MARY SONYA
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SONYA
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 1:5480 HEDGE BROOKE POINTE NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-7142
Mailing Address - Country:US
Mailing Address - Phone:404-960-5486
Mailing Address - Fax:
Practice Address - Street 1:5480 HEDGE BROOKE POINTE NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-7142
Practice Address - Country:US
Practice Address - Phone:404-960-5486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NTO15850171WH0202X
175T00000X
GANTO15850171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No171WH0202XOther Service ProvidersContractorHome Modifications
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00000000OtherN/A