Provider Demographics
NPI:1750311387
Name:JACKSON, NKENGE AYEOLA (MD)
Entity Type:Individual
Prefix:DR
First Name:NKENGE
Middle Name:AYEOLA
Last Name:JACKSON
Suffix:
Gender:F
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 60879
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31420-0879
Mailing Address - Country:US
Mailing Address - Phone:912-920-2995
Mailing Address - Fax:
Practice Address - Street 1:5354 REYNOLDS ST STE 420
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6011
Practice Address - Country:US
Practice Address - Phone:912-920-2995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-084664207V00000X
GA058969207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA106448409AMedicaid
OH2502787Medicaid
OHR84664OtherSUMMACARE
OH000000337650OtherANTHEM
OHR84664OtherSUMMACARE
OH000000337650OtherANTHEM
OH4137351Medicare ID - Type Unspecified