Healthcare Provider Details

I. General information

NPI: 1003731233
Provider Name (Legal Business Name): KYRA MCKENZIE JACKSON MSN, APRN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1297 HEMBREE RD STE 100
ROSWELL GA
30076-3814
US

IV. Provider business mailing address

104 PARK AVE SE
ATLANTA GA
30315-4033
US

V. Phone/Fax

Practice location:
  • Phone: 608-336-3363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberAPRN-CNM302876
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: