Provider Demographics
NPI:1457388019
Name:RAINER, JACKSON PATTEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:PATTEN
Last Name:RAINER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 FAYETTEVILLE RD SE STE A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2932
Mailing Address - Country:US
Mailing Address - Phone:404-636-1457
Mailing Address - Fax:404-636-7449
Practice Address - Street 1:3103 CLAIRMONT RD NE STE B
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-1043
Practice Address - Country:US
Practice Address - Phone:404-636-1457
Practice Address - Fax:404-636-7449
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1142103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G704720OtherPTAN
GA00387791BMedicaid
GA68BBFGF4Medicare UPIN
GA68BBGFXMedicare ID - Type Unspecified