Provider Demographics
NPI:1134310147
Name:DOBBS-JACKSON, RENEKA L (MD)
Entity Type:Individual
Prefix:DR
First Name:RENEKA
Middle Name:L
Last Name:DOBBS-JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RENEKA
Other - Middle Name:L
Other - Last Name:DOBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:420 E 2ND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3210
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:
Practice Address - Street 1:420 E 2ND AVE STE 103
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161
Practice Address - Country:US
Practice Address - Phone:706-509-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA064770207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA754116853CMedicaid
GA754116853CMedicaid