Healthcare Provider Details

I. General information

NPI: 1780626721
Provider Name (Legal Business Name): JOSEPH L JACKSON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 JONES AVE
WAYNESBORO GA
30830-1510
US

IV. Provider business mailing address

305 JONES AVE
WAYNESBORO GA
30830-1510
US

V. Phone/Fax

Practice location:
  • Phone: 706-554-5147
  • Fax: 706-554-6111
Mailing address:
  • Phone: 706-554-5147
  • Fax: 706-554-6111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number052277
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: