Provider Demographics
NPI:1164203204
Name:JACKSON, DIONNE (NP)
Entity type:Individual
Prefix:
First Name:DIONNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1757 ROCK QUARRY RD STE A
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7303
Mailing Address - Country:US
Mailing Address - Phone:678-284-6575
Mailing Address - Fax:
Practice Address - Street 1:125 KING AVE STE 200
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6710
Practice Address - Country:US
Practice Address - Phone:706-369-4478
Practice Address - Fax:063-536-6397
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN249589363L00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner