Provider Demographics
NPI:1235232430
Name:JACKSON, BILLIE LUKE (MD)
Entity Type:Individual
Prefix:
First Name:BILLIE
Middle Name:LUKE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 CHARTER BLVD
Mailing Address - Street 2:SUITE 2201
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4857
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:31210-4857
Practice Address - Country:US
Practice Address - Phone:478-477-5575
Practice Address - Fax:478-477-0707
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA30791207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000373513EMedicaid
GA000373513EMedicaid
GA07BDBFTMedicare ID - Type Unspecified