Provider Demographics
NPI:1154427615
Name:JACKSON, REGINALD ROBERTS (MD)
Entity type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:ROBERTS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 102321
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368
Mailing Address - Country:US
Mailing Address - Phone:404-367-3014
Mailing Address - Fax:404-367-3558
Practice Address - Street 1:35 COLLIER RD NW
Practice Address - Street 2:SUITE 635
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309
Practice Address - Country:US
Practice Address - Phone:404-367-3014
Practice Address - Fax:404-367-3558
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051007207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00932896AMedicaid
GA00932896AMedicaid
GAH54816Medicare UPIN