Provider Demographics
NPI:1982627279
Name:JACKSON, BEVERLY R (RN ANP)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W HILL ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6618
Mailing Address - Country:US
Mailing Address - Phone:229-225-1900
Mailing Address - Fax:229-225-3455
Practice Address - Street 1:119 W HILL ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6618
Practice Address - Country:US
Practice Address - Phone:229-225-1900
Practice Address - Fax:229-225-3455
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045920163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS48718Medicare UPIN
GA50BBCCDMedicare PIN