Healthcare Provider Details

I. General information

NPI: 1487332284
Provider Name (Legal Business Name): JONI JACKSON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JONI MELINDA JACKSON PMHNP

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/05/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 GLENRIDGE DR APT 106
SANDY SPRINGS GA
30342-1395
US

IV. Provider business mailing address

PO BOX 964
MONROE GA
30655-0964
US

V. Phone/Fax

Practice location:
  • Phone: 678-237-5538
  • Fax:
Mailing address:
  • Phone: 888-772-0076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberGAA-NP001470
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: