Healthcare Provider Details

I. General information

NPI: 1720911191
Provider Name (Legal Business Name): JUBRENZA RENAE JACKSON APC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2954 WARDLAW LN
BUFORD GA
30519-3828
US

IV. Provider business mailing address

2954 WARDLAW LN
BUFORD GA
30519-3828
US

V. Phone/Fax

Practice location:
  • Phone: 404-981-4415
  • Fax:
Mailing address:
  • Phone: 404-981-4415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC010813
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: