Provider Demographics
NPI:1033396841
Name:JACKSON, BETHANY WALL (MD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:WALL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:BETHANY
Other - Middle Name:JEAN
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 12938
Mailing Address - Street 2:C/O CLINIC MANAGEMENT
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703
Mailing Address - Country:US
Mailing Address - Phone:706-602-7800
Mailing Address - Fax:
Practice Address - Street 1:2112 SHORTER AVE NW STE 240
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2042
Practice Address - Country:US
Practice Address - Phone:706-368-8575
Practice Address - Fax:706-204-9430
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060642208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003132526AMedicaid
GA003132526BMedicaid
AL146978Medicaid
GA202I378166Medicare PIN