Healthcare Provider Details

I. General information

NPI: 1861874380
Provider Name (Legal Business Name): LAUREN JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2015
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3736 MIKE PADGETT HWY STE A
AUGUSTA GA
30906
US

IV. Provider business mailing address

PO BOX 947407
ATLANTA GA
30394-7407
US

V. Phone/Fax

Practice location:
  • Phone: 706-560-2273
  • Fax: 706-560-0903
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME171752
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: