Provider Demographics
NPI:1720193915
Name:JACKSON, JENNIFER M (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3432 MERCER UNIVERSITY DR.
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2088
Mailing Address - Country:US
Mailing Address - Phone:478-755-8366
Mailing Address - Fax:478-755-8399
Practice Address - Street 1:3432 MERCER UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-4902
Practice Address - Country:US
Practice Address - Phone:478-755-8366
Practice Address - Fax:478-755-8399
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0121761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice