Provider Demographics
NPI:1720666928
Name:JACKS, ANABELLA (MD)
Entity Type:Individual
Prefix:
First Name:ANABELLA
Middle Name:
Last Name:JACKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 BLACKHAWK TRL
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7132
Mailing Address - Country:US
Mailing Address - Phone:404-354-0570
Mailing Address - Fax:
Practice Address - Street 1:6511 SPRING BROOK AVE
Practice Address - Street 2:
Practice Address - City:RHINEBECK
Practice Address - State:NY
Practice Address - Zip Code:12572-3709
Practice Address - Country:US
Practice Address - Phone:845-790-2085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty