Healthcare Provider Details

I. General information

NPI: 1649228172
Provider Name (Legal Business Name): VANNA MANIGAULT JACKSON MD FAAP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

993 F JOHNSON FERRY RD STE 370
ATLANTA GA
30342
US

IV. Provider business mailing address

993 F JOHNSON FERRY RD STE 370
ATLANTA GA
30342
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-4611
  • Fax: 404-256-1759
Mailing address:
  • Phone: 404-252-4611
  • Fax: 404-256-1759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number043420
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: