Basic Information
| Provider Information | |||||||||
| NPI: | 1174761498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | LEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRANDENBERGER | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | LEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5670 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042551930 | ||||||||
| FaxNumber: | 4042551939 | ||||||||
| Practice Location | |||||||||
| Address1: | 5670 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042551930 | ||||||||
| FaxNumber: | 4042551939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2009 | ||||||||
| LastUpdateDate: | 02/14/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WX0200X | RN143526 | GA | Y | Nursing Service Providers | Registered Nurse | Oncology |
No ID Information.