Provider Demographics
NPI:1578232443
Name:JACKSON, ANDREA ROLANDA (PMHNP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ROLANDA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:864 LAKE ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-4516
Mailing Address - Country:US
Mailing Address - Phone:443-822-6648
Mailing Address - Fax:
Practice Address - Street 1:1202 TOWN PARK LN STE 300
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3477
Practice Address - Country:US
Practice Address - Phone:706-432-6866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN186919363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health