Provider Demographics
NPI:1164849352
Name:JACKSON, KYLE (MD, PHD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WOODRUFF CIRCLE WMB SUITE 51505
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-0001
Mailing Address - Country:US
Mailing Address - Phone:855-366-7989
Mailing Address - Fax:
Practice Address - Street 1:101 WOODRUFF CIRCLE WMB SUITE 51505
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-2109
Practice Address - Country:US
Practice Address - Phone:855-366-7989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA91328208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery