Provider Demographics
NPI:1982816674
Name:JACKSON, RONALD L (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
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 1:1020 NEW HOPE RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-7238
Mailing Address - Country:US
Mailing Address - Phone:404-691-3374
Mailing Address - Fax:404-505-1985
Practice Address - Street 1:5400 S COBB DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-7421
Practice Address - Country:US
Practice Address - Phone:404-794-7390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0348602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry