1487332284 NPI number — JONI JACKSON CHARBONNEAU PMHNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487332284 NPI number — JONI JACKSON CHARBONNEAU PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARBONNEAU
Provider First Name:
JONI
Provider Middle Name:
JACKSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACKSON
Provider Other First Name:
JONI
Provider Other Middle Name:
MELINDA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PMHNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487332284
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 964
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30655-0964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-772-0076
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1332 WESTON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30032-2551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-237-5538
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/11/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  GAA-NP001470 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com