Provider Demographics
NPI:1114296464
Name:BILLIE L. JACKSON, M.D., LLC
Entity Type:Organization
Organization Name:BILLIE L. JACKSON, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-477-5575
Mailing Address - Street 1:440 CHARTER BLVD
Mailing Address - Street 2:SUITE 2201
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-0724
Mailing Address - Country:US
Mailing Address - Phone:478-477-5575
Mailing Address - Fax:478-477-0707
Practice Address - Street 1:440 CHARTER BLVD
Practice Address - Street 2:SUITE 2201
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-0724
Practice Address - Country:US
Practice Address - Phone:478-477-5575
Practice Address - Fax:478-477-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030791207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000373513EMedicaid
GAD40232Medicare UPIN
GA000373513EMedicaid