Provider Demographics
NPI:1891668257
Name:JACKSON, COURTNEY NICOLE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
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 1:3345 KENSINGTON RD # 216
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-1512
Mailing Address - Country:US
Mailing Address - Phone:470-544-8275
Mailing Address - Fax:
Practice Address - Street 1:3345 KENSINGTON RD # 216
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1512
Practice Address - Country:US
Practice Address - Phone:470-544-8275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-24
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC7A2B8M7374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty