=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770510802
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAZEL ANITA JACKSON MN, RN, APRN,BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1670 CLAIRMONT RD
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30033-4004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-321-6111
-----------------------------------------------------
Fax | 404-327-4972
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1429 OAK KNOLL DR NE
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30012-4751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-918-1558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WM0705X
-----------------------------------------------------
Taxonomy Name | Medical-Surgical Registered Nurse
-----------------------------------------------------
License Number | R084397
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------