Healthcare Provider Details

I. General information

NPI: 1932311362
Provider Name (Legal Business Name): YOLANDA DENEEN JACKSON CAREPROVIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 WHISPERING PINES RD
ALBANY GA
31707-3562
US

IV. Provider business mailing address

1214 WHISPERING PINES RD
ALBANY GA
31707-3562
US

V. Phone/Fax

Practice location:
  • Phone: 229-889-8287
  • Fax:
Mailing address:
  • Phone: 229-889-8287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: