MEDICARE: MR. ROBERT WALLACE JACKSON JR.

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	253Z00000X	In Home Supportive Care Agency	PHCP010932	GA

General Provider Information

NPI Number	:	1932791993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT WALLACE JACKSON JR.

Provider Business Mailing Address
First Line	:	1355 TERRELL MILL RD SE BLDG 1462-125
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-5559
Country	:	US
Telephone Number	:	470-632-7400
Fax Number	:	470-524-0500

Provider Business Practice Location Address
First Line	:	1355 TERRELL MILL RD SE BLDG 1462-125
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-5559
Country	:	US
Telephone Number	:	470-632-7400
Fax Number	:	470-524-0500

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

Provider Enumeration Date	:	02/10/2021
Last Update Date	:	02/10/2021

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