Provider Demographics
NPI:1134721384
Name:JACKSON, FELTON LEWIS III
Entity type:Individual
Prefix:
First Name:FELTON
Middle Name:LEWIS
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 KYLES CIR
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-4695
Mailing Address - Country:US
Mailing Address - Phone:678-557-5770
Mailing Address - Fax:770-800-8127
Practice Address - Street 1:4190 MISTYMORN WAY
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-2591
Practice Address - Country:US
Practice Address - Phone:678-557-5770
Practice Address - Fax:770-800-8127
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060541970343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)