1194997270 NPI number — DR. PENNY TRONELL JACKSON D.C.

Table of content: DR. PENNY TRONELL JACKSON D.C. (NPI 1194997270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194997270 NPI number — DR. PENNY TRONELL JACKSON D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
PENNY
Provider Middle Name:
TRONELL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194997270
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLACOOCHEE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31650-1100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-381-0064
Provider Business Mailing Address Fax Number:
912-534-6176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1161 HIGHWAY 135 S
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
WILLACOOCHEE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31650-7747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-381-0064
Provider Business Practice Location Address Fax Number:
912-534-6176
Provider Enumeration Date:
03/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CHIR008305 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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