Provider Demographics
NPI:1023870862
Name:JACKSON, PENNY DENISE
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:DENISE
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 1:178 PROGRESS WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKY FACE
Mailing Address - State:GA
Mailing Address - Zip Code:30740-7748
Mailing Address - Country:US
Mailing Address - Phone:706-537-4777
Mailing Address - Fax:
Practice Address - Street 1:178 PROGRESS WAY
Practice Address - Street 2:
Practice Address - City:ROCKY FACE
Practice Address - State:GA
Practice Address - Zip Code:30740-7748
Practice Address - Country:US
Practice Address - Phone:706-537-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health