MEDICARE: DR. JEANINE ANGELA JACKSON AU.D., CCC-A

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	237600000X	Audiologist-Hearing Aid Fitter	AUD003626	GA

General Provider Information

NPI Number	:	1902166895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEANINE ANGELA JACKSON AU.D., CCC-A

Provider Business Mailing Address
First Line	:	3239 TELFORD TER SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-5447
Country	:	US
Telephone Number	:	404-346-1863
Fax Number	:

Provider Business Practice Location Address
First Line	:	3239 TELFORD TER SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-5447
Country	:	US
Telephone Number	:	404-346-1863
Fax Number	:

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

Provider Enumeration Date	:	05/24/2012
Last Update Date	:	09/28/2012

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