Provider Demographics
NPI:1588759211
Name:ANDERSON, JASON DALE (PA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:DALE
Last Name:ANDERSON
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 WELL BROOK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3873
Mailing Address - Country:US
Mailing Address - Phone:770-922-3023
Mailing Address - Fax:770-929-1016
Practice Address - Street 1:105 FISCHER MARKETPLACE LN STE 100
Practice Address - Street 2:
Practice Address - City:SHARPSBURG
Practice Address - State:GA
Practice Address - Zip Code:30277-3680
Practice Address - Country:US
Practice Address - Phone:678-633-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003238207R00000X
GA3238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA063339549PAMedicaid
GA97BBFKPMedicare ID - Type Unspecified
S95506Medicare UPIN