Provider Demographics
NPI:1992387823
Name:JACKSON, BIANCA JO
Entity Type:Individual
Prefix:MS
First Name:BIANCA
Middle Name:JO
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BIANCA
Other - Middle Name:JO
Other - Last Name:RUFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2508 SHANNON CT
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-6633
Mailing Address - Country:US
Mailing Address - Phone:706-284-1533
Mailing Address - Fax:706-284-1533
Practice Address - Street 1:2508 SHANNON CT
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-6633
Practice Address - Country:US
Practice Address - Phone:706-284-1533
Practice Address - Fax:706-284-1533
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2022-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA253Z00000X
320700000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities