Provider Demographics
NPI:1538133905
Name:JAGO, KENNETH S (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:S
Last Name:JAGO
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 1:125 OAKSIDE CT STE 101
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114
Mailing Address - Country:US
Mailing Address - Phone:770-479-3424
Mailing Address - Fax:770-720-3454
Practice Address - Street 1:125 OAKSIDE CT STE 101
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114
Practice Address - Country:US
Practice Address - Phone:770-479-3424
Practice Address - Fax:770-720-3454
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA29476207Q00000X
GA029476207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00380575CMedicaid
GA00380575CMedicaid