Healthcare Provider Details

I. General information

NPI: 1063828416
Provider Name (Legal Business Name): RHONDA RENEE JACKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RHONDA RENEE DOUGLAS

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 FOSTER DR SPC C
MCDONOUGH GA
30253-5346
US

IV. Provider business mailing address

156 FOSTER DR SPC C
MCDONOUGH GA
30253-5346
US

V. Phone/Fax

Practice location:
  • Phone: 770-968-9978
  • Fax: 770-968-9975
Mailing address:
  • Phone: 770-968-9978
  • Fax: 770-968-9975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD468479
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4301105792
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number85286
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number92856
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: