Provider Demographics
NPI:1134593353
Name:JACKSON, LAVERNE
Entity type:Individual
Prefix:
First Name:LAVERNE
Middle Name:
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 1:903 N COURT ST
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643-1315
Mailing Address - Country:US
Mailing Address - Phone:229-263-7147
Mailing Address - Fax:229-263-6318
Practice Address - Street 1:903 N COURT ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:GA
Practice Address - Zip Code:31643-1315
Practice Address - Country:US
Practice Address - Phone:229-263-7147
Practice Address - Fax:229-263-6318
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-27
Last Update Date:2015-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN130090261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN130090OtherPROFESSIONAL REGISTERED NURSE