Provider Demographics
NPI:1427818624
Name:JACKSON VINCENT, LEONIA
Entity type:Individual
Prefix:
First Name:LEONIA
Middle Name:
Last Name:JACKSON VINCENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 HEMLOCK STREET LN # 165
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2168
Mailing Address - Country:US
Mailing Address - Phone:478-633-1634
Mailing Address - Fax:
Practice Address - Street 1:777 HEMLOCK STREET LN # 165
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2168
Practice Address - Country:US
Practice Address - Phone:478-633-1634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-22
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA16004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program