MEDICARE: DR. CHERRY WYANT JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P1300X	Psychiatric Pharmacist	0022492	GA
2	1835P1300X	Psychiatric Pharmacist	6607	SC

General Provider Information

NPI Number	:	1760475248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHERRY WYANT JACKSON

Provider Business Mailing Address
First Line	:	220 BRADLEY POINT RD
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31410-3506
Country	:	US
Telephone Number	:	912-898-3567
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 BRADLEY POINT RD
Second Line	:
City	:	SAVANNAH
State	:	GA
Zip	:	31410-3506
Country	:	US
Telephone Number	:	912-898-3567
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	07/08/2007

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