Provider Demographics
NPI:1013311752
Name:JACKSON, WILLIAM THOMAS (MS, ATC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:THOMAS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MS, ATC
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 362
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:GA
Mailing Address - Zip Code:31811-0362
Mailing Address - Country:US
Mailing Address - Phone:706-325-8482
Mailing Address - Fax:
Practice Address - Street 1:1364 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1059
Practice Address - Country:US
Practice Address - Phone:404-727-7825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0020622255A2300X
390200000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program