Provider Demographics
NPI:1811949688
Name:JACKSON, KECIA STRAWTER (MD)
Entity type:Individual
Prefix:
First Name:KECIA
Middle Name:STRAWTER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KECIA
Other - Middle Name:ANTOINETTE
Other - Last Name:STRAWTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3495 PIEDMONT ROAD, NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-364-7070
Mailing Address - Fax:770-761-6626
Practice Address - Street 1:8011 MALL PARKWAY
Practice Address - Street 2:KAISER PERMANENTE STONECREST MEDICAL CENTER
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038
Practice Address - Country:US
Practice Address - Phone:678-323-7521
Practice Address - Fax:770-761-6626
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038978208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00617328IMedicaid
GA00617328IMedicaid