Individual
LEOPOLD L JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
303 PARKWAY DRIVE, NE, PMB 404, ATLANTA, GA 30312-1212
(404) 265-4520
(404) 265-3894
Mailing address
PO BOX 932925, ATLANTA, GA 31193-2925
(800) 364-9216
(423) 892-5838
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
047224
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000824216L
—
GA
05
—
000824216M
—
GA
01
—
1881631984
NPI
GA
01
—
1982637419
GROUP NPI
GA
01
—
300966
WELLCARE MEDICAID
GA
01
—
587007
BCBSGA (NSC)
GA
01
—
858272
BCBSGA (AMC)
GA
01
—
P00251519
RAILROAD MEDICARE
—
Enumeration date
05/31/2006
Last updated
12/20/2010
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