Healthcare Provider Details

I. General information

NPI: 1699024380
Provider Name (Legal Business Name): JACKSON SURGICAL ASSISTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 NORTHWINDS PKWY
ALPHARETTA GA
30009-2280
US

IV. Provider business mailing address

PO BOX 543 ALPHARETTA
ALPHARETTA GA
30009-0543
US

V. Phone/Fax

Practice location:
  • Phone: 877-230-9617
  • Fax: 877-281-8770
Mailing address:
  • Phone: 877-230-9627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number
License Number State

VIII. Authorized Official

Name: ANN H SCHAKER
Title or Position: BILLING DIRECTOR
Credential:
Phone: 877-230-9617