Provider Demographics
NPI:1548040496
Name:JACKSON, YULANDA MICHELLE
Entity type:Individual
Prefix:
First Name:YULANDA
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 RANKIN CIR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8688
Mailing Address - Country:US
Mailing Address - Phone:323-347-8669
Mailing Address - Fax:
Practice Address - Street 1:2200 PATRICK HENRY PKWY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-4207
Practice Address - Country:US
Practice Address - Phone:470-713-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN316186163WH0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0500XNursing Service ProvidersRegistered NurseHemodialysis