Provider Demographics
NPI:1831790526
Name:JACKSON, KIBIBI A (FNP-BC)
Entity type:Individual
Prefix:
First Name:KIBIBI
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 UPPER RIVERDALE RD SW
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2584
Mailing Address - Country:US
Mailing Address - Phone:770-996-9400
Mailing Address - Fax:
Practice Address - Street 1:483 UPPER RIVERDALE RD SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2584
Practice Address - Country:US
Practice Address - Phone:770-996-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-08
Last Update Date:2025-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN265070207Q00000X, 163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163WE0003XNursing Service ProvidersRegistered NurseEmergency