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General NPI Number Information
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NPI Number | 1306505854
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Entity Type | Individual
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Provider Name | KELLY NICOLE JACKSON FNP
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Gender | Female
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Dates
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Enumeration Date | 12/13/2021
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Last Update Date | 12/13/2021
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Provider Practice Location Address
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Address Line | 400 N STATE OF FRANKLIN RD
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City | JOHNSON CITY
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State | TN
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Zip | 37604-6035
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Country | US
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Telephone | 423-431-2922
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Fax |
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Provider Business Mailing Address
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Address Line | 2382 OLD STAGECOACH RD
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City | JONESBOROUGH
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State | TN
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Zip | 37659-4868
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Country | US
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Telephone | 423-431-2922
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 30680
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License Number State | TN
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