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General NPI Number Information
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NPI Number | 1306830062
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Entity Type | Individual
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Provider Name | MICHAEL S JACKSON MD
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Gender | Male
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Dates
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Enumeration Date | 09/08/2005
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Last Update Date | 08/12/2019
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Provider Practice Location Address
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Address Line | 506 RIVERSIDE PKWY NE STE 200
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City | ROME
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State | GA
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Zip | 30161-2902
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Country | US
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Telephone | 706-266-2383
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 40
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City | SILVER CREEK
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State | GA
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Zip | 30173-0040
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Country | US
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Telephone | 706-266-9090
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Fax | 706-204-8797
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 055376
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License Number State | GA
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