Healthcare Provider Details

I. General information

NPI: 1538953245
Provider Name (Legal Business Name): RUBY & PEARL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

2180 SATELLITE BLVD STE 400
DULUTH GA
30097-4927
US

IV. Provider business mailing address

1052 ASHTON PARK DR
LAWRENCEVILLE GA
30045-7277
US

V. Phone/Fax

Practice location:
  • Phone: 404-480-2760
  • Fax: 949-703-8760
Mailing address:
  • Phone: 404-480-2760
  • Fax: 949-703-8760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NICHELLE LATOYA JACKSON
Title or Position: OWNER
Credential: FNP-C, PMHNP-BC
Phone: 404-480-2760