MEDICARE: DR. JESSIKA RENEE JACKSON MD

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	208000000X	Pediatrics Physician	80311	GA

General Provider Information

NPI Number	:	1144614520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSIKA RENEE JACKSON MD

Provider Business Mailing Address
First Line	:	3200 HIGHLANDS PKWY SE STE 118
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30082-5192
Country	:	US
Telephone Number	:	404-220-7660
Fax Number	:	770-803-9191

Provider Business Practice Location Address
First Line	:	3200 HIGHLANDS PKWY SE STE 118
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30082-5192
Country	:	US
Telephone Number	:	404-220-7660
Fax Number	:	770-803-9191

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

Provider Enumeration Date	:	03/24/2015
Last Update Date	:	03/21/2023

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