Provider Demographics
NPI: | 1932525581 |
---|---|
Name: | JACKSON, VELLETTA ANN (RN, MSN, CRRN) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | VELLETTA |
Middle Name: | ANN |
Last Name: | JACKSON |
Suffix: | |
Gender: | F |
Credentials: | RN, MSN, CRRN |
Other - Prefix: | MRS |
Other - First Name: | VELLETTA |
Other - Middle Name: | ANN |
Other - Last Name: | JACKSON-LOVE |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | RN, MSN, CRRN |
Mailing Address - Street 1: | 2303 E ALBERSON DR |
Mailing Address - Street 2: | |
Mailing Address - City: | ALBANY |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 31721-2045 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 229-288-3879 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 611 PINE AVE |
Practice Address - Street 2: | |
Practice Address - City: | ALBANY |
Practice Address - State: | GA |
Practice Address - Zip Code: | 31701-2403 |
Practice Address - Country: | US |
Practice Address - Phone: | 229-288-3879 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2014-03-06 |
Last Update Date: | 2014-03-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 108011 | 133NN1002X, 163W00000X, 163WA0400X, 163WA2000X, 163WC0400X, 163WC1500X, 163WC1600X, 163WD0400X, 163WH0200X, 163WN1003X, 163WP0000X, 163WP0807X, 163WP0809X, 163WR0400X, 376G00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 163WC1500X | Nursing Service Providers | Registered Nurse | Community Health |
No | 133NN1002X | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
No | 163W00000X | Nursing Service Providers | Registered Nurse | |
No | 163WA0400X | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No | 163WA2000X | Nursing Service Providers | Registered Nurse | Administrator |
No | 163WC0400X | Nursing Service Providers | Registered Nurse | Case Management |
No | 163WC1600X | Nursing Service Providers | Registered Nurse | Continuing Education/Staff Development |
No | 163WD0400X | Nursing Service Providers | Registered Nurse | Diabetes Educator |
No | 163WH0200X | Nursing Service Providers | Registered Nurse | Home Health |
No | 163WN1003X | Nursing Service Providers | Registered Nurse | Nutrition Support |
No | 163WP0000X | Nursing Service Providers | Registered Nurse | Pain Management |
No | 163WP0807X | Nursing Service Providers | Registered Nurse | Psychiatric/Mental Health, Child & Adolescent |
No | 163WP0809X | Nursing Service Providers | Registered Nurse | Psychiatric/Mental Health, Adult |
No | 163WR0400X | Nursing Service Providers | Registered Nurse | Rehabilitation |
No | 376G00000X | Nursing Service Related Providers | Nursing Home Administrator |