Provider Demographics
NPI:1568434231
Name:JACKSON, JEANINE M (CNNP)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-534-8998
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-535-3611
Practice Address - Fax:770-535-7092
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN060702363LN0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000731497DMedicaid
GA302386OtherWELLCARE
GA000731497EMedicaid
GA000731497AMedicaid
GA302385OtherWELLCARE
GA000731497BMedicaid
GA000731497FMedicaid
GA302387OtherWELLCARE
GA10032991OtherAMERIGROUP
GA302375OtherWELLCARE