Individual
MR. ELLIS R JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
610 3RD ST, MACON, GA 31201-3294
(229) 344-6080
(229) 436-8649
Mailing address
427 FUSSELL RD, LEESBURG, GA 31763-5210
(229) 344-6080
(229) 436-8649
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
RN066377
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
334081730A
—
GA
01
—
P00220709
RR MEDICARE
GA
Enumeration date
11/02/2005
Last updated
04/12/2017
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