Provider Demographics
NPI:1366658734
Name:JACKSON, CHARLES E JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1506 TELFAIR ST
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-3908
Mailing Address - Country:US
Mailing Address - Phone:478-272-3446
Mailing Address - Fax:
Practice Address - Street 1:107 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2501
Practice Address - Country:US
Practice Address - Phone:478-864-3448
Practice Address - Fax:478-864-1288
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA014513207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111934Medicare Oscar/Certification