Provider Demographics
NPI:1598744542
Name:JACKSON, OSCAR D JR (MD)
Entity Type:Individual
Prefix:DR
First Name:OSCAR
Middle Name:D
Last Name:JACKSON
Suffix:JR
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 1:805 S HANSELL ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5560
Mailing Address - Country:US
Mailing Address - Phone:229-225-1357
Mailing Address - Fax:
Practice Address - Street 1:805 S HANSELL ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5560
Practice Address - Country:US
Practice Address - Phone:229-225-1357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030793174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00372523DMedicaid
GA00372523EMedicaid
GA16BDDPJ01Medicare PIN
GA16BDDPJMedicare PIN
GA00372523DMedicaid