Provider Demographics
NPI:1891779096
Name:JACKSON, LEWIS W (MD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2959 SHARPSBURG MCCOLLUM RD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2297
Mailing Address - Country:US
Mailing Address - Phone:770-502-2000
Mailing Address - Fax:770-502-2009
Practice Address - Street 1:2959 SHARPSBURG MCCOLLUM RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2297
Practice Address - Country:US
Practice Address - Phone:770-502-2000
Practice Address - Fax:770-502-2009
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA042294208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000717131EMedicaid