Provider Demographics
NPI:1962653816
Name:JACKSON, TIFFANEY S (MD)
Entity Type:Individual
Prefix:
First Name:TIFFANEY
Middle Name:S
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 1705
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:706-854-6008
Mailing Address - Fax:706-774-7230
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-774-5795
Practice Address - Fax:706-774-5792
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063076208M00000X, 207R00000X
GA63076207R00000X
PAMT 188545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I115419OtherMEDICARE PTAN
GA934400412AMedicaid
GA934400412BOtherGEORGIA MEDICAID
GA934400412AMedicaid