1568434231 NPI number — JEANINE M. JACKSON CNNP

Table of content: (NPI 1699388520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568434231 NPI number — JEANINE M. JACKSON CNNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
JEANINE
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNNP
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:
1568434231
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 658
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30503-0658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-718-1122
Provider Business Mailing Address Fax Number:
770-534-8998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 JESSE JEWELL PKWY SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-535-3611
Provider Business Practice Location Address Fax Number:
770-535-7092
Provider Enumeration Date:
02/06/2006

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: 363LN0000X , with the licence number:  RN060702 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: RN060702 , 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: 000731497D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 302386 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000731497E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000731497A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 302385 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000731497B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000731497F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 302387 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10032991 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 302375 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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