Provider Demographics
NPI:1265576581
Name:JACKSON, PHILLIP GAYNOR (DO)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:GAYNOR
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5500 ROCKTON WOOD WAY SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8904
Mailing Address - Country:US
Mailing Address - Phone:404-494-9540
Mailing Address - Fax:404-344-3706
Practice Address - Street 1:5500 ROCKTON WOOD WAY SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-8904
Practice Address - Country:US
Practice Address - Phone:404-494-9540
Practice Address - Fax:404-344-3706
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA048248207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine