Provider Demographics
NPI:1245742329
Name:JACKSON, CHANDA WALLER (NP)
Entity Type:Individual
Prefix:
First Name:CHANDA
Middle Name:WALLER
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 1:550 PEACHTREE STREET
Mailing Address - Street 2:DAVIS FISHER BUILDING, OFFICE 3245A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308
Mailing Address - Country:US
Mailing Address - Phone:404-686-7858
Mailing Address - Fax:
Practice Address - Street 1:95 COLLIER RD NW STE 5015
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1721
Practice Address - Country:US
Practice Address - Phone:404-605-6517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213894363L00000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology