Provider Demographics
NPI:1700060522
Name:JACKSON, JUREA JUANITA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JUREA
Middle Name:JUANITA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:JUREA
Other - Middle Name:JUANITA
Other - Last Name:COPELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:5028 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30830-7533
Mailing Address - Country:US
Mailing Address - Phone:706-554-9923
Mailing Address - Fax:
Practice Address - Street 1:351 S LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:GA
Practice Address - Zip Code:30830-9686
Practice Address - Country:US
Practice Address - Phone:706-554-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN074224164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPN074224OtherLPN LICENSE NUMBER