Healthcare Provider Details

I. General information

NPI: 1164304580
Provider Name (Legal Business Name): JACKSON BRYANT COOK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2025
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 DIXIE ST STE 220
CARROLLTON GA
30117-3889
US

IV. Provider business mailing address

5725 BRENDA DR SW
MABLETON GA
30126-3121
US

V. Phone/Fax

Practice location:
  • Phone: 770-812-8640
  • Fax: 770-838-8650
Mailing address:
  • Phone: 256-278-8842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP316440
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: