Healthcare Provider Details

I. General information

NPI: 1235196684
Provider Name (Legal Business Name): JENNIFER JACQUELINE JACKSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 PEACHTREE RD NE STE 645
ATLANTA GA
30309-1476
US

IV. Provider business mailing address

2001 PEACHTREE RD NE STE 645
ATLANTA GA
30309-1476
US

V. Phone/Fax

Practice location:
  • Phone: 404-605-2050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number002415
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002415
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: