MEDICARE: RHONDA RENEE JACKSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	MD468479	PA
2	207L00000X	Anesthesiology Physician	4301105792	MI
3	207L00000X	Anesthesiology Physician	85286	SC
4	207L00000X	Anesthesiology Physician	92856	GA

General Provider Information

NPI Number	:	1063828416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RHONDA RENEE JACKSON M.D.

Provider Business Mailing Address
First Line	:	156 FOSTER DR SPC C
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-5346
Country	:	US
Telephone Number	:	770-968-9978
Fax Number	:	770-968-9975

Provider Business Practice Location Address
First Line	:	156 FOSTER DR SPC C
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-5346
Country	:	US
Telephone Number	:	770-968-9978
Fax Number	:	770-968-9975

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2014
Last Update Date	:	06/07/2023

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