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General NPI Number Information
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NPI Number | 1376939124
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Entity Type | Individual
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Provider Name | TONI JACKSON
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Gender | Female
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Dates
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Enumeration Date | 04/08/2015
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Last Update Date | 05/27/2025
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Provider Practice Location Address
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Address Line | 4280 N VALDOSTA RD
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City | VALDOSTA
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State | GA
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Zip | 31602-6814
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Country | US
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Telephone | 229-259-4135
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Fax |
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Provider Business Mailing Address
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Address Line | 1782 CASWELL PKWY
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City | MARIETTA
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State | GA
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Zip | 30060-9267
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Country | US
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Telephone | 404-808-2160
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Fax |
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 174217
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License Number State | FL
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