Provider Demographics
NPI:1609102243
Name:JACKSON, REBECCA DOTT (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:DOTT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 BUBBLING CREEK RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-2104
Mailing Address - Country:US
Mailing Address - Phone:404-333-2911
Mailing Address - Fax:
Practice Address - Street 1:755 WALTHER RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8725
Practice Address - Country:US
Practice Address - Phone:404-252-7618
Practice Address - Fax:678-843-5525
Is Sole Proprietor?:No
Enumeration Date:2009-11-01
Last Update Date:2009-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5467363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical