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General NPI Number Information
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NPI Number | 1255465217
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Entity Type | Organization
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Legal Business Name | NORTHCREST FAMILY MEDICINE LLC
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Dates
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Enumeration Date | 03/14/2007
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Last Update Date | 03/22/2013
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Provider Practice Location Address
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Address Line | 7768 CUMMING HWY SUITE 300
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City | CANTON
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State | GA
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Zip | 30114-9314
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Country | US
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Telephone | 770-720-2113
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Fax | 770-704-7365
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Provider Business Mailing Address
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Address Line | 7768 CUMMING HWY. STE 300
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City | CANTON
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State | GA
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Zip | 30114
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Country | US
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Telephone | 770-720-2113
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Fax | 770-704-7365
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Authorized Official
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Title or Position | MD / OWNER
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Name | MR. JOHN RICHARD JACKSON
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Credential | M.D.
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Telephone | 770-655-1408
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 056102
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License Number State | GA
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