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General NPI Number Information
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NPI Number | 1093879769
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Entity Type | Individual
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Provider Name | SOPHIA EVETTE JACKSON NP
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Gender | Female
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Dates
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Enumeration Date | 12/20/2006
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Last Update Date | 09/16/2013
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Provider Practice Location Address
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Address Line | 1950 BUFORD HWY CVS CAREMARK MINUTE CLINIC
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City | BUFORD
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State | GA
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Zip | 30518-3673
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Country | US
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Telephone | 770-945-7286
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Fax |
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Provider Business Mailing Address
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Address Line | 4249 BRENTWOOD DR
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City | BUFORD
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State | GA
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Zip | 30518-9008
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Country | US
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Telephone | 770-292-8634
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Fax | 770-965-2269
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN117221
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License Number State | GA
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