Provider Demographics
NPI:1477076792
Name:JACKSON, TREMEZE SCOTT (PMHNP-BC, FNP-C)
Entity Type:Individual
Prefix:
First Name:TREMEZE
Middle Name:SCOTT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PMHNP-BC, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5330 BROOKSTONE DR NW STE 250
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-7183
Mailing Address - Country:US
Mailing Address - Phone:770-405-9855
Mailing Address - Fax:
Practice Address - Street 1:3295 RIVER EXCHANGE DR STE 211
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4204
Practice Address - Country:US
Practice Address - Phone:770-405-9855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2023-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN228481363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health