Individual
ALICE JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1389 GORDON RD, MORELAND, GA 30259-2541
(770) 251-8209
Mailing address
1389 GORDON RD, MORELAND, GA 30259-2541
Taxonomy
Speciality
Code
Description
License number
State
3747A0650X
Attendant Care Provider
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0000000
DEPARTMENT OF VA AFFAIRS
—
Enumeration date
08/28/2019
Last updated
08/28/2019
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