Healthcare Provider Details

I. General information

NPI: 1730523887
Provider Name (Legal Business Name): JACKSON THOMAS LONDEREE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 06/06/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 TULLIE RD NE FL 2
ATLANTA GA
30329-2309
US

IV. Provider business mailing address

1400 TULLIE RD NE FL 2
ATLANTA GA
30329-2309
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax: 404-785-9071
Mailing address:
  • Phone: 404-785-5437
  • Fax: 404-785-9071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number78075
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: