Provider Demographics
NPI:1982717575
Name:JACKSON, JOHN M JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 S LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3144
Mailing Address - Country:US
Mailing Address - Phone:706-845-0544
Mailing Address - Fax:
Practice Address - Street 1:304 S LEWIS ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3144
Practice Address - Country:US
Practice Address - Phone:706-845-0544
Practice Address - Fax:706-812-8791
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0103311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice