Healthcare Provider Details

I. General information

NPI: 1538165386
Provider Name (Legal Business Name): EUGENE HOOKS JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 04/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 NORMAN DORMINY DR
FITZGERALD GA
31750-8858
US

IV. Provider business mailing address

PO BOX 1447
FITZGERALD GA
31750-1447
US

V. Phone/Fax

Practice location:
  • Phone: 229-423-9561
  • Fax:
Mailing address:
  • Phone: 229-423-9561
  • Fax: 229-424-7097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number022793
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: