Provider Demographics
NPI:1790529329
Name:JACKSON, KERIANA EDWINA
Entity type:Individual
Prefix:
First Name:KERIANA
Middle Name:EDWINA
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 1:1331 ROSE TERRACE CIR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-9046
Mailing Address - Country:US
Mailing Address - Phone:678-622-6687
Mailing Address - Fax:
Practice Address - Street 1:1331 ROSE TERRACE CIR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-9046
Practice Address - Country:US
Practice Address - Phone:678-622-6687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
GA174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies