Basic Information
| Provider Information | |||||||||
| NPI: | 1336163112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | EDITH | ||||||||
| MiddleName: | SINCLAIR | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.W. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | EDITH | ||||||||
| OtherMiddleName: | SINCLAIR | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S.W. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | VAMC -1 FREEDOM WAY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309046285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067330188 | ||||||||
| FaxNumber: | 7068233960 | ||||||||
| Practice Location | |||||||||
| Address1: | 3465 EVANS TO LOCKS RD | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309074907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068638287 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW000980 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.