Healthcare Provider Details

I. General information

NPI: 1306700091
Provider Name (Legal Business Name): QUENITRA Q JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 DAWSON RD
ALBANY GA
31707-1673
US

IV. Provider business mailing address

80 DOGWOOD ST
CAMILLA GA
31730-5373
US

V. Phone/Fax

Practice location:
  • Phone: 229-606-6508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835C0207X
TaxonomyCompounded Sterile Preparations Pharmacist
License NumberRPH035962
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: