Provider Demographics
NPI:1508485426
Name:MONTRYM, JACKSON DAVIS (MD)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:DAVIS
Last Name:MONTRYM
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 1:3580 MASSEE LN STE F
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2586
Mailing Address - Country:US
Mailing Address - Phone:706-596-8667
Mailing Address - Fax:
Practice Address - Street 1:3580 MASSEE LN STE F
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2586
Practice Address - Country:US
Practice Address - Phone:706-596-8667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA96309208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics