Provider Demographics
NPI:1710965637
Name:JACKSON, ROBERT E JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:517 CHESNEE HWY STE A
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-2709
Practice Address - Country:US
Practice Address - Phone:864-487-7655
Practice Address - Fax:864-487-7818
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10879207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCG5856067OtherMEDICARE PIN
SC018797Medicaid
SCSCG5856084OtherMEDICARE PIN
SCSCG585J577OtherMEDICARE PIN
080075169OtherRR MCR