Provider Demographics
NPI:1932525581
Name:JACKSON, VELLETTA ANN (RN, MSN, CRRN)
Entity type:Individual
Prefix:MRS
First Name:VELLETTA
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, MSN, CRRN
Other - Prefix:MRS
Other - First Name:VELLETTA
Other - Middle Name:ANN
Other - Last Name:JACKSON-LOVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, MSN, CRRN
Mailing Address - Street 1:2303 E ALBERSON DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-2045
Mailing Address - Country:US
Mailing Address - Phone:229-288-3879
Mailing Address - Fax:
Practice Address - Street 1:611 PINE AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-2403
Practice Address - Country:US
Practice Address - Phone:229-288-3879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA108011133NN1002X, 163W00000X, 163WA0400X, 163WA2000X, 163WC0400X, 163WC1500X, 163WC1600X, 163WD0400X, 163WH0200X, 163WN1003X, 163WP0000X, 163WP0807X, 163WP0809X, 163WR0400X, 376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support
No163WP0000XNursing Service ProvidersRegistered NursePain Management
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163WR0400XNursing Service ProvidersRegistered NurseRehabilitation
No376G00000XNursing Service Related ProvidersNursing Home Administrator