Basic Information
| Provider Information | |||||||||
| NPI: | 1629220017 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6605 ABERCORN ST | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314055815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123545357 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11705 MERCY BLVD | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314191711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128196000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2008 | ||||||||
| LastUpdateDate: | 06/16/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 005442 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 005442 | 01 | GA | PA LICENSES | OTHER |