Provider Demographics
NPI:1225502768
Name:ZZIWA, JACKIE KABAHUMA (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:KABAHUMA
Last Name:ZZIWA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 HICKORY HAVEN TER
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6413
Mailing Address - Country:US
Mailing Address - Phone:404-453-2337
Mailing Address - Fax:
Practice Address - Street 1:405 GROVE ST STE 201
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1270
Practice Address - Country:US
Practice Address - Phone:339-666-8516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN169490363LP0808X, 163W00000X
MARN2390242363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse