Individual
MS. MARY SONYA JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
5480 HEDGE BROOKE POINTE NW, ACWORTH, GA 30101-7142
(404) 960-5486
Mailing address
5480 HEDGE BROOKE POINTE NW, ACWORTH, GA 30101-7142
(404) 960-5486
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
NTO15850
GA
171WH0202X
Home Modifications Contractor
NTO15850
—
175T00000X
Peer Specialist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00000000
N/A
GA
Enumeration date
10/06/2020
Last updated
10/06/2020
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