Provider Demographics
NPI:1144367749
Name:JACKSON, NERISSA (PA-C)
Entity type:Individual
Prefix:MS
First Name:NERISSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1253
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-1253
Mailing Address - Country:US
Mailing Address - Phone:315-403-4961
Mailing Address - Fax:
Practice Address - Street 1:7386 FRIENDSHIP SPRINGS BLVD STE J
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-5548
Practice Address - Country:US
Practice Address - Phone:470-451-0646
Practice Address - Fax:470-451-0647
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030340363A00000X
NY013802363A00000X
GA7277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400012279Medicare PIN