Provider Demographics
NPI:1063640563
Name:JACKSON DENT, SANDRA NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:NICOLE
Last Name:JACKSON DENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 FOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2919
Mailing Address - Country:US
Mailing Address - Phone:770-978-5000
Mailing Address - Fax:
Practice Address - Street 1:2240 FOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2919
Practice Address - Country:US
Practice Address - Phone:770-978-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336.091542208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics