Provider Demographics
NPI:1184031320
Name:KRISTY H JACKSON MD PC
Entity Type:Organization
Organization Name:KRISTY H JACKSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:H
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-629-3933
Mailing Address - Street 1:PO BOX 441
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-0441
Mailing Address - Country:US
Mailing Address - Phone:404-629-3933
Mailing Address - Fax:404-629-3935
Practice Address - Street 1:920 DANNON VW SW
Practice Address - Street 2:STE 3104
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2157
Practice Address - Country:US
Practice Address - Phone:404-629-3933
Practice Address - Fax:404-629-3935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0606432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty