Provider Demographics
NPI:1194281287
Name:JACKSON, RYAN THERON
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:THERON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 225
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-0225
Mailing Address - Country:US
Mailing Address - Phone:478-697-2700
Mailing Address - Fax:
Practice Address - Street 1:1112 PARKWAY CIR N
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340-6312
Practice Address - Country:US
Practice Address - Phone:478-697-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician