Provider Demographics
NPI:1780005496
Name:JACKSON, ROBERT EARL JR
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EARL
Last Name:JACKSON
Suffix:JR
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 1:17 WICKHAM DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-6328
Mailing Address - Country:US
Mailing Address - Phone:706-689-6676
Mailing Address - Fax:
Practice Address - Street 1:17 WICKHAM DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-6328
Practice Address - Country:US
Practice Address - Phone:706-689-6676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034283667172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker