Provider Demographics
NPI:1952150682
Name:JACKSON, DONNA MICHELLE
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MICHELLE
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 1:3861 RADCLIFFE BLVD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-6056
Mailing Address - Country:US
Mailing Address - Phone:140-449-3563
Mailing Address - Fax:
Practice Address - Street 1:3861 RADCLIFFE BLVD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-6056
Practice Address - Country:US
Practice Address - Phone:140-449-3563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver