Provider Demographics
NPI:1578450383
Name:JACKSON, SANDY
Entity type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 CLEBORN STREET
Mailing Address - Street 2:
Mailing Address - City:CUTHBERT
Mailing Address - State:GA
Mailing Address - Zip Code:39840
Mailing Address - Country:US
Mailing Address - Phone:229-732-3981
Mailing Address - Fax:229-732-6621
Practice Address - Street 1:72 CLEBORN STREET
Practice Address - Street 2:
Practice Address - City:CUTHBERT
Practice Address - State:GA
Practice Address - Zip Code:39840
Practice Address - Country:US
Practice Address - Phone:229-732-3981
Practice Address - Fax:229-732-6621
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker