Healthcare Provider Details

I. General information

NPI: 1144192568
Provider Name (Legal Business Name): RICHARD JACKSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2025
Last Update Date: 10/24/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 CRESTE DR
DECATUR GA
30035-4135
US

IV. Provider business mailing address

811 CRESTE DR
DECATUR GA
30035-4135
US

V. Phone/Fax

Practice location:
  • Phone: 678-881-7888
  • Fax:
Mailing address:
  • Phone: 678-881-7888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: