Provider Demographics
NPI:1982111704
Name:JACKSON, CARROLL DAVIS (APRN)
Entity Type:Individual
Prefix:MRS
First Name:CARROLL
Middle Name:DAVIS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 18TH ST E STE 400
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3684
Mailing Address - Country:US
Mailing Address - Phone:229-353-3422
Mailing Address - Fax:229-353-6060
Practice Address - Street 1:172 MJ TAYLOR RD
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-3497
Practice Address - Country:US
Practice Address - Phone:229-896-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN167907363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily