Provider Demographics
NPI:1831790526
Name:JACKSON, RUTH KIBIBI R
Entity type:Individual
Prefix:
First Name:RUTH KIBIBI
Middle Name:R
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 1:678 YORK VIEW DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30011-4628
Mailing Address - Country:US
Mailing Address - Phone:678-710-4265
Mailing Address - Fax:
Practice Address - Street 1:678 YORK VIEW DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:GA
Practice Address - Zip Code:30011-4628
Practice Address - Country:US
Practice Address - Phone:678-710-4265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN265070163WE0003X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WE0003XNursing Service ProvidersRegistered NurseEmergency