Provider Demographics
NPI:1265420574
Name:JACKSON, TANJELA M (MD)
Entity type:Individual
Prefix:DR
First Name:TANJELA
Middle Name:M
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 1:3620 MARTIN LUTHER KING JR DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-3711
Mailing Address - Country:US
Mailing Address - Phone:404-696-7300
Mailing Address - Fax:
Practice Address - Street 1:3620 M L KING JR DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-3711
Practice Address - Country:US
Practice Address - Phone:404-696-7300
Practice Address - Fax:404-699-3514
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054755207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2490487OtherUNITED HEALTH CARE
GA748360477FMedicaid
GA748360477HMedicaid
GA748360477Medicaid
GA7889745OtherAETNA
GA52152577OtherBCBS
GA7368440OtherCIGNA
GA748360477GMedicaid
GA748360477KMedicaid
GA748360477EMedicaid
GA748360477IMedicaid
GA748360477JMedicaid
GA748360477JMedicaid
GA748360477GMedicaid