Provider Demographics
NPI:1194997270
Name:JACKSON, PENNY TRONELL (DC)
Entity type:Individual
Prefix:DR
First Name:PENNY
Middle Name:TRONELL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DC
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 1100
Mailing Address - Street 2:
Mailing Address - City:WILLACOOCHEE
Mailing Address - State:GA
Mailing Address - Zip Code:31650-1100
Mailing Address - Country:US
Mailing Address - Phone:912-381-0064
Mailing Address - Fax:912-534-6176
Practice Address - Street 1:1161 HIGHWAY 135 S
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLACOOCHEE
Practice Address - State:GA
Practice Address - Zip Code:31650-7747
Practice Address - Country:US
Practice Address - Phone:912-381-0064
Practice Address - Fax:912-534-6176
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008305111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor