Healthcare Provider Details

I. General information

NPI: 1881969079
Provider Name (Legal Business Name): JADE STAFFORD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JADE JACKSON M.D.

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 11/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE 8TH FLOOR MOT
ATLANTA GA
30308-2212
US

IV. Provider business mailing address

550 PEACHTREE ST NE 8TH FLOOR MOT
ATLANTA GA
30308-2212
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3401
  • Fax:
Mailing address:
  • Phone: 404-778-3401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number75908
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: