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NPI Code Detail

MEDICARE: DR. BYRON ANDRA JACKSON MD

MEDICARE: DR. BYRON ANDRA 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
1207R00000XInternal Medicine Physician08028RLA

General Provider Information

NPI Number : 1821167263
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. BYRON ANDRA JACKSON MD
Provider Business Mailing Address
First Line : PO BOX 740012
Second Line :
City : ATLANTA
State : GA
Zip : 30374-0012
Country : US
Telephone Number : 773-352-1515
Fax Number : 312-929-0373
Provider Business Practice Location Address
First Line : 653 W 70TH ST
Second Line :
City : SHREVEPORT
State : LA
Zip : 71106-2949
Country : US
Telephone Number : 318-636-8389
Fax Number : 318-636-8389
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/07/2006
Last Update Date : 05/14/2024

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