MEDICARE: MRS. VELLETTA ANN JACKSON RN, MSN, CRRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133NN1002X	Nutrition Education Nutritionist	108011	GA
2	163W00000X	Registered Nurse	108011	GA
3	163WA0400X	Addiction (Substance Use Disorder) Registered Nurse	108011	GA
4	163WA2000X	Administrator Registered Nurse	108011	GA
5	163WC0400X	Case Management Registered Nurse	108011	GA
6	163WC1500X	Community Health Registered Nurse	108011	GA
7	163WC1600X	Continuing Education/Staff Development Registered Nurse	108011	GA
8	163WD0400X	Diabetes Educator Registered Nurse	108011	GA
9	163WH0200X	Home Health Registered Nurse	108011	GA
10	163WN1003X	Nutrition Support Registered Nurse	108011	GA
11	163WP0000X	Pain Management Registered Nurse	108011	GA
12	163WP0807X	Child & Adolescent Psychiatric/Mental Health Registered Nurse	108011	GA
13	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse	108011	GA
14	163WR0400X	Rehabilitation Registered Nurse	108011	GA
15	376G00000X	Nursing Home Administrator	108011	GA

General Provider Information

NPI Number	:	1932525581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VELLETTA ANN JACKSON RN, MSN, CRRN

Provider Business Mailing Address
First Line	:	2303 E ALBERSON DR
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31721-2045
Country	:	US
Telephone Number	:	229-288-3879
Fax Number	:

Provider Business Practice Location Address
First Line	:	611 PINE AVE
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31701-2403
Country	:	US
Telephone Number	:	229-288-3879
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2014
Last Update Date	:	03/06/2014

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