Robert Wallace Jackson Jr.

Primary specialty

In Home Supportive Care AgencyTaxonomy code 253Z00000X

License

PHCP010932 Issued in GA

Practice address

1355 Terrell Mill Rd SE BLDG 1462-125
Marietta, GA 30067-5559

Phone

(470) 632-7400

Fax

(470) 524-0500

NPI assigned

Feb 10, 2021

Last updated

Feb 10, 2021By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1612915200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1612915200000",
    "number": "1932791993",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1355 TERRELL MILL RD SE BLDG 1462-125",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300675559",
            "telephone_number": "470-632-7400",
            "fax_number": "470-524-0500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1355 TERRELL MILL RD SE BLDG 1462-125",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300675559",
            "telephone_number": "470-632-7400",
            "fax_number": "470-524-0500"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "ROBERT",
        "middle_name": "WALLACE",
        "name_prefix": "Mr.",
        "name_suffix": "Jr.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2021-02-10",
        "last_updated": "2021-02-10",
        "certification_date": "2021-02-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "253Z00000X",
            "taxonomy_group": "",
            "desc": "In Home Supportive Care",
            "state": "GA",
            "license": "PHCP010932",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jabria Jackson, SLP
• Jayce Jackson, RBT
• Kierra Jackson
• Kristy Hendricks Jackson, M.D.
• Rebecca Jackson, FNP
• Sheree Jackson, LPC
• Thiha Cadet Jackson, PA-A
• Toni Ann Jackson, OTR/L
• Jacob D Taylor (Injury Therapy Group)
• Mirna Jacob-Pintro, PA-C

• In Home Supportive Care Agency in Marietta, GA
• Providers in Marietta, GA by specialty
• In Home Supportive Care Agency in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 10, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.