Provider Demographics
NPI:1962026013
Name:JACKSON, ALEXIS JOAN (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:JOAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LEXI
Other - Middle Name:JOAN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1105 E 50TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-4021
Mailing Address - Country:US
Mailing Address - Phone:904-704-7291
Mailing Address - Fax:
Practice Address - Street 1:303 HARRIS INDUSTRIAL BLVD STE 3
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8854
Practice Address - Country:US
Practice Address - Phone:912-537-9355
Practice Address - Fax:912-335-4804
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9793363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant