Healthcare Provider Details

I. General information

NPI: 1437360716
Provider Name (Legal Business Name): GLENDA S JACKSON RN C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 HARDEE AVE
FORT MCPHERSON GA
30330
US

IV. Provider business mailing address

1741 CEDAR WALK LN
CONLEY GA
30288-1745
US

V. Phone/Fax

Practice location:
  • Phone: 404-464-0266
  • Fax: 404-464-0475
Mailing address:
  • Phone: 404-361-0853
  • Fax: 404-464-0475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN083685
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: