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General NPI Number Information
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NPI Number | 1407236045
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Entity Type | Individual
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Provider Name | PATRICE M JACKSON-WEATHERS CNA
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Gender | Female
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Dates
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Enumeration Date | 06/08/2015
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Last Update Date | 02/10/2024
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Provider Practice Location Address
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Address Line | 4266 LINDSEY DR
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City | DECATUR
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State | GA
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Zip | 30035-1927
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Country | US
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Telephone | 470-965-3741
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Fax |
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Provider Business Mailing Address
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Address Line | 325 WILLOW RIDGE WAY
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City | AVONDALE ESTATES
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State | GA
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Zip | 30002-1284
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Country | US
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Telephone | 470-829-1973
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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 | 376K00000X
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Taxonomy Name | Nurse's Aide
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License Number | 344541
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 376K00000X
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Taxonomy Name | Nurse's Aide
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License Number | 560249
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 376K00000X
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Taxonomy Name | Nurse's Aide
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License Number | CN0014212008
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 376G00000X
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Taxonomy Name | Nursing Home Administrator
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License Number |
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License Number State |
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