Provider Demographics
NPI:1629010707
Name:JACKSON, RANDY H (PA)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:H
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA
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 2938
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-2938
Mailing Address - Country:US
Mailing Address - Phone:770-536-2146
Mailing Address - Fax:770-536-7895
Practice Address - Street 1:743 SPRING ST NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3715
Practice Address - Country:US
Practice Address - Phone:770-536-2146
Practice Address - Fax:770-536-7895
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002048363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA624253146AMedicaid
GAS43367Medicare UPIN
GA624253146AMedicaid