Provider Demographics
NPI:1679847057
Name:JACKSON, KALITA HIGGINBOTHAM (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KALITA
Middle Name:HIGGINBOTHAM
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MEDICAL CENTER BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3332
Mailing Address - Country:US
Mailing Address - Phone:678-629-7139
Mailing Address - Fax:
Practice Address - Street 1:500 MEDICAL CENTER BLVD STE 310
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3332
Practice Address - Country:US
Practice Address - Phone:678-629-7139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN191958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily