Provider Demographics
NPI:1548066970
Name:JACKSON, MALLORY CHARLENE
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:CHARLENE
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 PALMETTO TYRONE RD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1501
Mailing Address - Country:US
Mailing Address - Phone:770-608-5019
Mailing Address - Fax:
Practice Address - Street 1:540 PALMETTO TYRONE RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1501
Practice Address - Country:US
Practice Address - Phone:770-608-5019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician