Provider Demographics
NPI:1972303329
Name:JACKSON, DEMETRIA A (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 CHASE RDG
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-0300
Mailing Address - Country:US
Mailing Address - Phone:404-865-4215
Mailing Address - Fax:
Practice Address - Street 1:270 HERITAGE WALK
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3875
Practice Address - Country:US
Practice Address - Phone:982-977-0618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA246390363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health