Provider Demographics
NPI:1619705324
Name:JACKSON, DOROTHY L
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:L
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 1:147 BLUE POOL DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1416
Mailing Address - Country:US
Mailing Address - Phone:229-305-8282
Mailing Address - Fax:
Practice Address - Street 1:147 BLUE POOL DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1416
Practice Address - Country:US
Practice Address - Phone:229-305-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator