Basic Information
Provider Information | |||||||||
NPI: | 1033396841 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON | ||||||||
FirstName: | BETHANY | ||||||||
MiddleName: | WALL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WALL | ||||||||
OtherFirstName: | BETHANY | ||||||||
OtherMiddleName: | JEAN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | P.A.-C. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 420 E 2ND AVE | ||||||||
Address2: | SUITE 103 | ||||||||
City: | ROME | ||||||||
State: | GA | ||||||||
PostalCode: | 301613209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7065093000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 304 SHORTER AVE NW STE 105 | ||||||||
Address2: |   | ||||||||
City: | ROME | ||||||||
State: | GA | ||||||||
PostalCode: | 301654256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7062914880 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2008 | ||||||||
LastUpdateDate: | 07/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 060642 | GA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 003132526B | 05 | GA |   | MEDICAID | 003132526A | 05 | GA |   | MEDICAID | 146978 | 05 | AL |   | MEDICAID |