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General NPI Number Information
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NPI Number | 1043484645
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Entity Type | Individual
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Provider Name | KRISTY HENDRICKS JACKSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 04/15/2008
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Last Update Date | 10/15/2019
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Provider Practice Location Address
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Address Line | 2540 WINDY HILL RD SE
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City | MARIETTA
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State | GA
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Zip | 30067-8605
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Country | US
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Telephone | 770-644-1570
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Fax |
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Provider Business Mailing Address
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Address Line | 475 FAIRBURN RD SW
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City | ATLANTA
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State | GA
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Zip | 30331-1907
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Country | US
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Telephone | 404-691-9627
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 060643
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License Number State | GA
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