Provider Demographics
NPI:1659787034
Name:JACKSON, NICOLE STANLEY (NP-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:STANLEY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:S
Other - Last Name:MASSENGALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 371
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31096-0371
Mailing Address - Country:US
Mailing Address - Phone:478-864-3448
Mailing Address - Fax:478-864-1288
Practice Address - Street 1:116 SMITH ST
Practice Address - Street 2:
Practice Address - City:TENNILLE
Practice Address - State:GA
Practice Address - Zip Code:31089-1465
Practice Address - Country:US
Practice Address - Phone:478-552-1620
Practice Address - Fax:478-864-1288
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN143548363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF0414179OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS
GARN143548OtherGEORGIA SECRETARY OF STATE