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General NPI Number Information
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NPI Number | 1326647199
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Entity Type | Individual
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Provider Name | BREIANE JACKSON LICENSED CPHT
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Gender | Female
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Dates
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Enumeration Date | 10/22/2020
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Last Update Date | 10/22/2020
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Provider Practice Location Address
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Address Line | 2790 COBB PKWY NW
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City | KENNESAW
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State | GA
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Zip | 30152-3455
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Country | US
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Telephone | 770-793-1838
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Fax |
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Provider Business Mailing Address
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Address Line | 4624 UNICORN PT
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City | POWDER SPRINGS
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State | GA
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Zip | 30127-5374
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Country | US
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Telephone | 770-361-1315
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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 | 183700000X
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Taxonomy Name | Pharmacy Technician
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License Number | PHTC051863
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License Number State | GA
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