Provider Demographics
NPI:1508455189
Name:JACKSON, NICOLETTE
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 LOCKHAVEN CIR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-3521
Mailing Address - Country:US
Mailing Address - Phone:770-912-8801
Mailing Address - Fax:770-936-1937
Practice Address - Street 1:1303 LOCKHAVEN CIR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-3521
Practice Address - Country:US
Practice Address - Phone:770-912-8801
Practice Address - Fax:770-936-1937
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0030036955376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide