Basic Information
| Provider Information | |||||||||
| NPI: | 1134310147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOBBS-JACKSON | ||||||||
| FirstName: | RENEKA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DOBBS | ||||||||
| OtherFirstName: | RENEKA | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 420 E 2ND AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 420 E 2ND AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 064770 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 754116853C | 05 | GA | MEDICAID |