Provider Demographics
NPI:1134208929
Name:JACKSON, ANNE MARIE (PT)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 CLARIDGE CURV
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-2627
Mailing Address - Country:US
Mailing Address - Phone:678-545-0951
Mailing Address - Fax:
Practice Address - Street 1:3200 SHAKERAG HL
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-6511
Practice Address - Country:US
Practice Address - Phone:770-487-0760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004476225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT004476OtherSTATE LISC NUMBER