Healthcare Provider Details

I. General information

NPI: 1992352421
Provider Name (Legal Business Name): COURTNEY JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 GEORGIA AVE SE SUITE 206
ATLANTA GA
30312
US

IV. Provider business mailing address

250 GEORGIA AVE SE SUITE 206
ATLANTA GA
30312
US

V. Phone/Fax

Practice location:
  • Phone: 202-441-3364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: