Provider Demographics
NPI:1932645389
Name:JACKSON, LETREACE ANDREA
Entity Type:Individual
Prefix:
First Name:LETREACE
Middle Name:ANDREA
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 1:5984 BROOKSIDE CT SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2896
Mailing Address - Country:US
Mailing Address - Phone:904-487-2305
Mailing Address - Fax:
Practice Address - Street 1:5984 BROOKSIDE CT SE
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-2896
Practice Address - Country:US
Practice Address - Phone:904-487-2305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN255613163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse