Provider Demographics
NPI:1710011408
Name:JACKSON, ANTAURES D (DC)
Entity Type:Individual
Prefix:DR
First Name:ANTAURES
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 PHOENIX BLVD
Mailing Address - Street 2:SUITE 450
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-5594
Mailing Address - Country:US
Mailing Address - Phone:770-909-0590
Mailing Address - Fax:770-909-1045
Practice Address - Street 1:1720 PHOENIX BLVD
Practice Address - Street 2:SUITE 450
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5594
Practice Address - Country:US
Practice Address - Phone:770-909-0590
Practice Address - Fax:770-909-1045
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6713111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU83651Medicare UPIN
GAGRP4391Medicare ID - Type Unspecified