Provider Demographics
NPI:1568591287
Name:JACKSON, ANDREW LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 206
Mailing Address - Street 2:
Mailing Address - City:WILLACOOCHEE
Mailing Address - State:GA
Mailing Address - Zip Code:31650
Mailing Address - Country:US
Mailing Address - Phone:912-534-5164
Mailing Address - Fax:912-534-5263
Practice Address - Street 1:600 MCCRANIE AVENUE
Practice Address - Street 2:
Practice Address - City:WILLACOOCHIE
Practice Address - State:GA
Practice Address - Zip Code:31650
Practice Address - Country:US
Practice Address - Phone:912-534-5164
Practice Address - Fax:912-534-5263
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA99391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice