Provider Demographics
NPI:1952360851
Name:JACKSON, LARETTE DENISE (CRNA)
Entity Type:Individual
Prefix:
First Name:LARETTE
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 CUMBERLAND PKWY SE
Mailing Address - Street 2:STE #3414
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6136
Mailing Address - Country:US
Mailing Address - Phone:770-596-3498
Mailing Address - Fax:
Practice Address - Street 1:2451 CUMBERLAND PKWY SE
Practice Address - Street 2:STE #3414
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-6136
Practice Address - Country:US
Practice Address - Phone:832-283-7792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN104440367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000887928Medicaid
GA000887928Medicaid
GA511I430454Medicare PIN