Provider Demographics
NPI:1467547836
Name:JACKSON, JAMES W JR (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:450 GEORGIA AVE
Mailing Address - Street 2:STE B
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458
Mailing Address - Country:US
Mailing Address - Phone:912-489-4123
Mailing Address - Fax:912-764-4977
Practice Address - Street 1:450 GEORGIA AVE
Practice Address - Street 2:STE B
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-489-4123
Practice Address - Fax:912-764-4977
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA034372207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000569687FMedicaid
GA000569687DMedicaid
GA000569687TMedicaid
GA366237OtherWELLCARE
GA390006768OtherRAILROAD MEDICARE
GA000569687QMedicaid
GA000569687RMedicaid
GA000569687VMedicaid
GA000569687XMedicaid
GA000569687EMedicaid
GA000569687GMedicaid
GA10063368OtherAMERIGROUP
GA000569687HMedicaid
GA000569687SMedicaid
GA000569687VMedicaid