Individual
JEANINE M. JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CNNP
Contact information
Practice address
725 JESSE JEWELL PKWY SE, GAINESVILLE, GA 30501-3834
(770) 535-3611
(770) 535-7092
Mailing address
PO BOX 658, GAINESVILLE, GA 30503-0658
(770) 718-1122
(770) 534-8998
Taxonomy
Speciality
Code
Description
License number
State
363LN0000X
Neonatal Nurse Practitioner
RN060702
GA
363LP0200X
Pediatric Nurse Practitioner
Primary
RN060702
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000731497A
—
GA
05
—
000731497B
—
GA
05
—
000731497D
—
GA
05
—
000731497E
—
GA
05
—
000731497F
—
GA
01
—
10032991
AMERIGROUP
GA
01
—
302375
WELLCARE
GA
01
—
302385
WELLCARE
GA
01
—
302386
WELLCARE
GA
01
—
302387
WELLCARE
GA
Enumeration date
02/06/2006
Last updated
10/25/2018
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