Provider Demographics
NPI:1730523887
Name:LONDEREE, JACKSON THOMAS (DO)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:THOMAS
Last Name:LONDEREE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 TULLIE RD NE FL 2
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2309
Mailing Address - Country:US
Mailing Address - Phone:404-785-5437
Mailing Address - Fax:404-785-9071
Practice Address - Street 1:1400 TULLIE RD NE FL 2
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2309
Practice Address - Country:US
Practice Address - Phone:404-785-5437
Practice Address - Fax:404-785-9071
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA78075208000000X
GA078075208000000X
TXQ8288208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX360163501Medicaid
TX360163502Medicaid
TX360163502Medicaid