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General NPI Number Information
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NPI Number | 1750311387
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Entity Type | Individual
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Provider Name | NKENGE AYEOLA JACKSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 07/03/2006
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Last Update Date | 09/11/2011
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Provider Practice Location Address
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Address Line | 5354 REYNOLDS ST STE 420
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City | SAVANNAH
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State | GA
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Zip | 31405-6011
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Country | US
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Telephone | 912-920-2995
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 60879
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City | SAVANNAH
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State | GA
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Zip | 31420-0879
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Country | US
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Telephone | 912-920-2995
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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 | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 35-084664
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 058969
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License Number State | GA
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