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General NPI Number Information
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NPI Number | 1285588673
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Entity Type | Individual
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Provider Name | VIVIAN JACKSON
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Gender | Female
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Dates
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Enumeration Date | 02/24/2026
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Last Update Date | 03/09/2026
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Provider Practice Location Address
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Address Line | 3945 HOLCOMB BRIDGE RD
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City | NORCROSS
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State | GA
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Zip | 30092-5252
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Country | US
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Telephone | 770-840-8045
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Fax |
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Provider Business Mailing Address
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Address Line | 4922 OXFORD POND DR
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City | CHARLOTTE
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State | NC
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Zip | 28262-4714
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Country | US
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Telephone | 770-840-8045
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Fax |
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | P24685
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | CP053417T
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License Number State | GA
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