Provider Demographics
NPI:1063828416
Name:JACKSON, RHONDA RENEE (MD)
Entity Type:Individual
Prefix:
First Name:RHONDA
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RHONDA
Other - Middle Name:RENEE
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:156 FOSTER DR SPC C
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-5346
Mailing Address - Country:US
Mailing Address - Phone:770-968-9978
Mailing Address - Fax:770-968-9975
Practice Address - Street 1:156 FOSTER DR SPC C
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5346
Practice Address - Country:US
Practice Address - Phone:770-968-9978
Practice Address - Fax:770-968-9975
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD468479207L00000X
MI4301105792207L00000X
SC85286207L00000X
GA92856207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology