Provider Demographics
NPI:1144809427
Name:JACKSON, NICOLE NAVIKA (CPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:NAVIKA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 SCALES RD APT 4311
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2530
Mailing Address - Country:US
Mailing Address - Phone:678-717-9342
Mailing Address - Fax:
Practice Address - Street 1:1035 SCALES RD APT 4311
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2530
Practice Address - Country:US
Practice Address - Phone:678-717-9342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2024-06-30
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy