MEDICARE: KIBIBI A JACKSON FNP-BC

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	207Q00000X	Family Medicine Physician	RN265070	GA
2	163WE0003X	Emergency Registered Nurse	RN265070	GA

General Provider Information

NPI Number	:	1831790526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIBIBI A JACKSON FNP-BC

Provider Business Mailing Address
First Line	:	483 UPPER RIVERDALE RD SW
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274-2584
Country	:	US
Telephone Number	:	770-996-9400
Fax Number	:

Provider Business Practice Location Address
First Line	:	483 UPPER RIVERDALE RD SW
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274-2584
Country	:	US
Telephone Number	:	770-996-9400
Fax Number	:

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

Provider Enumeration Date	:	11/08/2020
Last Update Date	:	09/27/2025

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