Provider Demographics
NPI:1225016454
Name:JACKSON, KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12080 WILDWOOD SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1887
Mailing Address - Country:US
Mailing Address - Phone:770-475-3361
Mailing Address - Fax:770-664-4431
Practice Address - Street 1:1360 UPPER HEMBREE RD STE 201B
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1230
Practice Address - Country:US
Practice Address - Phone:770-475-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027575207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00377539BMedicaid
GA00377539CMedicaid
GA00377539BMedicaid
GAD40233Medicare UPIN