Provider Demographics
NPI:1013345925
Name:JACKSON, EDWINA SUE (RN)
Entity Type:Individual
Prefix:
First Name:EDWINA
Middle Name:SUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1988
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31702-1988
Mailing Address - Country:US
Mailing Address - Phone:229-430-6061
Mailing Address - Fax:229-430-6002
Practice Address - Street 1:1120 W BROAD AVE
Practice Address - Street 2:SUITE C 4
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-4397
Practice Address - Country:US
Practice Address - Phone:229-430-6061
Practice Address - Fax:229-430-6002
Is Sole Proprietor?:No
Enumeration Date:2013-10-31
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN171447163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse