Healthcare Provider Details

I. General information

NPI: 1881214872
Provider Name (Legal Business Name): ROGER LEE JACKSON II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2020
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 CLIFTON RD SE
ATLANTA GA
30316-2229
US

IV. Provider business mailing address

713 CLIFTON RD SE
ATLANTA GA
30316-2229
US

V. Phone/Fax

Practice location:
  • Phone: 404-246-5444
  • Fax:
Mailing address:
  • Phone: 404-246-5444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number40076
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: