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General NPI Number Information
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NPI Number | 1184031320
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Entity Type | Organization
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Legal Business Name | KRISTY H JACKSON MD PC
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Dates
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Enumeration Date | 07/21/2014
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Last Update Date | 07/21/2014
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Provider Practice Location Address
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Address Line | 920 DANNON VW SW STE 3104
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City | ATLANTA
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State | GA
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Zip | 30331-2157
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Country | US
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Telephone | 404-629-3933
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Fax | 404-629-3935
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Provider Business Mailing Address
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Address Line | PO BOX 441
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City | FAIRBURN
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State | GA
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Zip | 30213-0441
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Country | US
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Telephone | 404-629-3933
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Fax | 404-629-3935
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Authorized Official
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Title or Position | CEO
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Name | KRISTY H JACKSON
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Credential | MD
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Telephone | 404-629-3933
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 060643
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License Number State | GA
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