Provider Demographics
NPI:1689958837
Name:JACKSON, AMANDA HOLLOMAN (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:HOLLOMAN
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 1:550 PEACHTREE ST NE STE 1275
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2240
Mailing Address - Country:US
Mailing Address - Phone:404-872-3121
Mailing Address - Fax:404-872-3119
Practice Address - Street 1:550 PEACHTREE ST NE STE 1275
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2240
Practice Address - Country:US
Practice Address - Phone:404-872-3121
Practice Address - Fax:404-872-3119
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN097491363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00311409AMedicaid