MEDICARE: JACKSONS POINT OF LIGHT FAMILY MEDICINE INC.

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MD 26806	OTHER	AL	AL LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	056705	OTHER	GA	GA LICENSE

General Provider Information

NPI Number	:	1578758553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONS POINT OF LIGHT FAMILY MEDICINE INC.

Provider Business Mailing Address
First Line	:	PO BOX 1045
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36868-1045
Country	:	US
Telephone Number	:	334-291-5255
Fax Number	:	877-395-0710

Provider Business Practice Location Address
First Line	:	1810 STADIUM DR
Second Line	:	SUITE 210
City	:	PHENIX CITY
State	:	AL
Zip	:	36867-3177
Country	:	US
Telephone Number	:	334-291-5255
Fax Number	:	877-395-0710

Authorized Official
Title or Position	:	ADMINISTRATON/COO
Name	:	MR. DERRIC N JACKSON
Credential	:
Telephone Number	:	334-291-5255

Provider Enumeration Date	:	09/12/2007
Last Update Date	:	03/07/2023

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