1225097124 NPI number — AMINA JACKSON ISOM CRNA

Table of content: AMINA JACKSON ISOM CRNA (NPI 1225097124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225097124 NPI number — AMINA JACKSON ISOM CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ISOM
Provider First Name:
AMINA
Provider Middle Name:
JACKSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACKSON
Provider Other First Name:
AMINA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1225097124
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 740209
Provider Second Line Business Mailing Address:
DEPT 1029
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-0209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-360-1566
Provider Business Mailing Address Fax Number:
941-358-9818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5671 PEACHTREE DUNWOODY RD NE
Provider Second Line Business Practice Location Address:
SUITE 680
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-705-6985
Provider Business Practice Location Address Fax Number:
404-851-9950
Provider Enumeration Date:
03/20/2006

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: 367500000X , with the licence number:  RN063448 , 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)

  • Identifier: 000556795 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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