Provider Demographics
NPI:1164203204
Name:JACKSON, DIONNE (NP)
Entity Type:Individual
Prefix:
First Name:DIONNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1757 ROCK QUARRY RD STE A
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7303
Mailing Address - Country:US
Mailing Address - Phone:678-284-6575
Mailing Address - Fax:
Practice Address - Street 1:1757 ROCK QUARRY RD STE A
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7303
Practice Address - Country:US
Practice Address - Phone:678-284-6575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN249589207RX0202X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology