Healthcare Provider Details

I. General information

NPI: 1649106428
Provider Name (Legal Business Name): CATHERINE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 06/20/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 GARDNERS MILL RD
AUGUSTA GA
30907-3793
US

IV. Provider business mailing address

117 GARDNERS MILL RD
AUGUSTA GA
30907-3793
US

V. Phone/Fax

Practice location:
  • Phone: 706-631-9961
  • Fax:
Mailing address:
  • Phone: 706-631-9961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN317481
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: