Provider Demographics
NPI:1740398338
Name:JACKSON, CALVIN R
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 WRIGHTSBORO RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4777
Mailing Address - Country:US
Mailing Address - Phone:706-736-5244
Mailing Address - Fax:706-736-5246
Practice Address - Street 1:2123 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4777
Practice Address - Country:US
Practice Address - Phone:706-736-5244
Practice Address - Fax:706-736-5246
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031265207R00000X
SC16449207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000623796BMedicaid
SC164495Medicaid
GA11BDMQRMedicare PIN
SCE683137611Medicare ID - Type Unspecified