Individual
DR. KEITH JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1360 UPPER HEMBREE RD STE 201B, ROSWELL, GA 30076-1230
(770) 475-3361
Mailing address
12080 WILDWOOD SPRINGS DR, ROSWELL, GA 30075-1887
(770) 475-3361
(770) 664-4431
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
027575
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00377539B
—
GA
05
—
00377539C
—
GA
Enumeration date
01/06/2006
Last updated
10/15/2019
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