MEDICARE: LARETTE DENISE JACKSON CRNA

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	367500000X	Certified Registered Nurse Anesthetist	RN104440	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952360851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARETTE DENISE JACKSON CRNA

Provider Business Mailing Address
First Line	:	2451 CUMBERLAND PKWY SE
Second Line	:	STE #3414
City	:	ATLANTA
State	:	GA
Zip	:	30339-6136
Country	:	US
Telephone Number	:	770-596-3498
Fax Number	:

Provider Business Practice Location Address
First Line	:	2451 CUMBERLAND PKWY SE
Second Line	:	STE #3414
City	:	ATLANTA
State	:	GA
Zip	:	30339-6136
Country	:	US
Telephone Number	:	832-283-7792
Fax Number	:

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

Provider Enumeration Date	:	03/20/2006
Last Update Date	:	02/18/2009

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