| Doctor Name: | LAVERNE JACKSON |
| NPI Number: | 1134593353 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | RN130090 |
| Business Practice Address: | 903 N Court St Quitman, GA - 316431315 |
| Business Phone Number: | 2292637147 |
| Business Fax Number: | 2292636318 |
| Mailing Address: | 903 N Court St, QUITMAN |
| State: | GA |
| Postal Code: | 316431315 |
| Phone Number: | 2292637147 |
| Fax Number: | 2292636318 |
| NPI Enumeration Date: | 11/27/2015 |
| NPI Last Update Date: | 11/27/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | RN130090 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |