Provider Demographics
NPI:1881631984
Name:JACKSON, LEOPOLD L (MD)
Entity Type:Individual
Prefix:
First Name:LEOPOLD
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
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 932925
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2925
Mailing Address - Country:US
Mailing Address - Phone:800-364-9216
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:303 PARKWAY DRIVE, NE
Practice Address - Street 2:PMB 404
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1212
Practice Address - Country:US
Practice Address - Phone:404-265-4520
Practice Address - Fax:404-265-3894
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047224207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1881631984OtherNPI
GA587007OtherBCBSGA (NSC)
P00251519OtherRAILROAD MEDICARE
GA000824216MMedicaid
GA000824216LMedicaid
GA858272OtherBCBSGA (AMC)
GA300966OtherWELLCARE MEDICAID
GA1982637419OtherGROUP NPI
$$$$$$$$$OtherCHAMPUS/TRICARE
GA1881631984OtherNPI
GA1982637419OtherGROUP NPI