Provider Demographics
NPI:1881214872
Name:JACKSON, ROGER LEE II
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:LEE
Last Name:JACKSON
Suffix:II
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 1:713 CLIFTON RD SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2229
Mailing Address - Country:US
Mailing Address - Phone:404-246-5444
Mailing Address - Fax:
Practice Address - Street 1:713 CLIFTON RD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-2229
Practice Address - Country:US
Practice Address - Phone:404-246-5444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA40076146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate