MEDICARE: DR. TODD JACKSON JR. MD, MPH

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	207P00000X	Emergency Medicine Physician	90618	GA

General Provider Information

NPI Number	:	1821627225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TODD JACKSON JR. MD, MPH

Provider Business Mailing Address
First Line	:	203 HILLTOP DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30315-6019
Country	:	US
Telephone Number	:	404-983-5256
Fax Number	:

Provider Business Practice Location Address
First Line	:	5665 NEW NORTHSIDE DR STE 200
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-4617
Country	:	US
Telephone Number	:	404-778-5975
Fax Number	:	404-778-2630

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

Provider Enumeration Date	:	04/07/2020
Last Update Date	:	08/17/2023

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