Provider Demographics
NPI:1174761498
Name:JACKSON, KELLY LEN (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LEN
Other - Last Name:BRANDENBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:771 OLD NORCROSS RD STE 165
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4979
Mailing Address - Country:US
Mailing Address - Phone:678-442-3121
Mailing Address - Fax:404-255-1939
Practice Address - Street 1:771 OLD NORCROSS RD STE 165
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4979
Practice Address - Country:US
Practice Address - Phone:678-442-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2025-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN143526163WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0200XNursing Service ProvidersRegistered NurseOncology