Provider Demographics
NPI:1164304580
Name:COOK, JACKSON BRYANT
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:BRYANT
Last Name:COOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 BRENDA DR SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-3121
Mailing Address - Country:US
Mailing Address - Phone:256-278-8842
Mailing Address - Fax:
Practice Address - Street 1:706 DIXIE ST STE 220
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3889
Practice Address - Country:US
Practice Address - Phone:770-812-8640
Practice Address - Fax:770-838-8650
Is Sole Proprietor?:No
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN316440363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily