MEDICARE: JENNIFER W JACKSON APRN, FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WA2000X	Administrator Registered Nurse	RN141785	GA
2	363LF0000X	Family Nurse Practitioner	APRN-NP141785	GA

General Provider Information

NPI Number	:	1639251069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER W JACKSON APRN, FNP-C

Provider Business Mailing Address
First Line	:	204 GORDON ST
Second Line	:
City	:	WASHINGTON
State	:	GA
Zip	:	30673-1604
Country	:	US
Telephone Number	:	706-678-2622
Fax Number	:	706-678-3115

Provider Business Practice Location Address
First Line	:	204 GORDON ST
Second Line	:
City	:	WASHINGTON
State	:	GA
Zip	:	30673-1604
Country	:	US
Telephone Number	:	706-678-2622
Fax Number	:	706-678-3115

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2006
Last Update Date	:	10/20/2025

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