Provider Demographics
NPI:1982865499
Name:FREEMAN-JACKSON, CHERYL DENISE (DDS)
Entity type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:DENISE
Last Name:FREEMAN-JACKSON
Suffix:
Gender:F
Credentials:DDS
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 5678
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906
Mailing Address - Country:US
Mailing Address - Phone:706-653-7058
Mailing Address - Fax:706-660-1940
Practice Address - Street 1:2206 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906
Practice Address - Country:US
Practice Address - Phone:706-653-7057
Practice Address - Fax:706-660-1940
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0114651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009975545Medicaid