Healthcare Provider Details

I. General information

NPI: 1093879769
Provider Name (Legal Business Name): SOPHIA EVETTE JACKSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 BUFORD HWY CVS CAREMARK MINUTE CLINIC
BUFORD GA
30518-3673
US

IV. Provider business mailing address

4249 BRENTWOOD DR
BUFORD GA
30518-9008
US

V. Phone/Fax

Practice location:
  • Phone: 770-945-7286
  • Fax:
Mailing address:
  • Phone: 770-292-8634
  • Fax: 770-965-2269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN117221
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: