Provider Demographics
NPI:1306505854
Name:JACKSON, KELLY NICOLE (FNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2382 OLD STAGECOACH RD
Mailing Address - Street 2:
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-4868
Mailing Address - Country:US
Mailing Address - Phone:423-431-2922
Mailing Address - Fax:
Practice Address - Street 1:400 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-431-2922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30680363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily