Provider Demographics
NPI:1780626721
Name:JACKSON, JOSEPH L JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:L
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:305 JONES AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30830-1510
Mailing Address - Country:US
Mailing Address - Phone:706-554-5147
Mailing Address - Fax:706-554-6111
Practice Address - Street 1:305 JONES AVE
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:GA
Practice Address - Zip Code:30830-1510
Practice Address - Country:US
Practice Address - Phone:706-554-5147
Practice Address - Fax:706-554-6111
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA052277207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA040331441AMedicaid
GA040331441BMedicaid
GAH49808Medicare UPIN
GA08BBXMVMedicare PIN