Provider Demographics
NPI:1417216375
Name:JACKSON, JUSTIN M (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
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 1:6325 HOSPITAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097
Mailing Address - Country:US
Mailing Address - Phone:678-474-7000
Mailing Address - Fax:
Practice Address - Street 1:1455 MONTREAL RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-8100
Practice Address - Country:US
Practice Address - Phone:404-251-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA76288207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology