MEDICARE: ANEE SOPHIA 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	208600000X	Surgery Physician	4301507139	MI
2	208600000X	Surgery Physician	96960	GA

General Provider Information

NPI Number	:	1265828883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANEE SOPHIA JACKSON MD

Provider Business Mailing Address
First Line	:	125 PARKWOOD LN
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-2857
Country	:	US
Telephone Number	:	913-221-9410
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 PEACHTREE ST NE STE 1430
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-2242
Country	:	US
Telephone Number	:	404-778-3712
Fax Number	:	404-778-0820

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

Provider Enumeration Date	:	04/10/2015
Last Update Date	:	08/23/2023

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