| Doctor Name: | ITELYA JACKSON |
| NPI Number: | 1811352412 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | RN |
| License Number: | |
| Business Practice Address: | 6957 Pine Shadow Way Winston, GA - 301872150 |
| Business Phone Number: | 6785404446 |
| Business Fax Number: | 6785404426 |
| Mailing Address: | 8491 Hospital Dr # 135, DOUGLASVILLE |
| State: | GA |
| Postal Code: | 301342412 |
| Phone Number: | 6785404446 |
| Fax Number: | 6785404426 |
| NPI Enumeration Date: | 12/23/2015 |
| NPI Last Update Date: | 12/23/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 253Z00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Agencies |
| Taxonomy Classification: | In Home Supportive Care |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An In Home Supportive Care Agency provides services in the patient |