Provider Demographics
NPI:1548671316
Name:JACKSON, JUDY MARIE
Entity type:Individual
Prefix:MS
First Name:JUDY
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5941 WILERSON RD.
Mailing Address - Street 2:W
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-1506
Mailing Address - Country:US
Mailing Address - Phone:678-284-1355
Mailing Address - Fax:678-284-1355
Practice Address - Street 1:5941 WILERSON RD.
Practice Address - Street 2:
Practice Address - City:REX
Practice Address - State:GA
Practice Address - Zip Code:30273-1506
Practice Address - Country:US
Practice Address - Phone:678-284-1355
Practice Address - Fax:678-284-1355
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031-01-129-1311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home