Healthcare Provider Details

I. General information

NPI: 1437261617
Provider Name (Legal Business Name): R. ELLIOTT JACKSON GERIATRICS,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 WEIGELIA RD NE
ATLANTA GA
30345-3969
US

IV. Provider business mailing address

3904 N DRUID HILLS RD #222
DECATUR GA
30033-3105
US

V. Phone/Fax

Practice location:
  • Phone: 404-213-3672
  • Fax: 770-458-1596
Mailing address:
  • Phone: 770-458-1594
  • Fax: 770-458-1596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number047774
License Number StateGA

VIII. Authorized Official

Name: RAMSEY ELLIOTT JACKSON
Title or Position: OWNER
Credential: M.D.
Phone: 404-213-3672