Provider Demographics
NPI:1477821155
Name:JACKSON, ALOYSIUS (MD)
Entity Type:Individual
Prefix:
First Name:ALOYSIUS
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 1:304 TURNER MCCALL BLVD SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-5621
Mailing Address - Country:US
Mailing Address - Phone:770-324-5131
Mailing Address - Fax:
Practice Address - Street 1:301 TURNER MCCALL BLVD
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165
Practice Address - Country:US
Practice Address - Phone:706-509-4340
Practice Address - Fax:706-291-2147
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018004381207Q00000X
IL134079207Q00000X
SC37435207Q00000X
TXQ0769207Q00000X
GA77026207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine