Individual
TIFFANEY S. JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
2260 WRIGHTSBORO RD, AUGUSTA, GA 30904-4764
(706) 774-5795
Mailing address
PO BOX 1705, AUGUSTA, GA 30903-1705
(706) 854-6008
(706) 774-7230
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
063076
GA
208M00000X
Hospitalist Physician
063076
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
202I115419
MEDICARE PTAN
GA
05
—
934400412A
—
GA
01
—
934400412B
GEORGIA MEDICAID
GA
Enumeration date
10/08/2008
Last updated
06/06/2024
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