Basic Information
| Provider Information | |||||||||
| NPI: | 1013311752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | M.S., ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 362 | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 318110362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063258482 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1364 CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047277825 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2014 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT002062 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.