Basic Information
| Provider Information | |||||||||
| NPI: | 1891860144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARD | ||||||||
| FirstName: | JACKSON | ||||||||
| MiddleName: | P | ||||||||
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| NameSuffix: | IV | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE | ||||||||
| Address2: | NINE PIEDMONT CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045045678 | ||||||||
| FaxNumber: | 7709944747 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 TOWNPARK LN NW | ||||||||
| Address2: | TOWN PARK COMPREHENSIVE MEDICAL CENTER | ||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301445579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705145401 | ||||||||
| FaxNumber: | 7709944747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 03220 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.