Provider Demographics
NPI:1730268046
Name:JACKSON, MICHAEL JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5311 PAULSEN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4800
Mailing Address - Country:US
Mailing Address - Phone:912-355-1111
Mailing Address - Fax:912-352-7136
Practice Address - Street 1:5311 PAULSEN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4800
Practice Address - Country:US
Practice Address - Phone:912-355-1111
Practice Address - Fax:912-352-7136
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038019207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA038019OtherLICENSE #
GA00729473AMedicaid
GA00729473AMedicaid
GA038019OtherLICENSE #
127798Medicare ID - Type Unspecified
GA00729473AMedicaid