Bethany Wall Jackson, M.D.

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

060642 Issued in GA

Practice address

2112 Shorter Ave NW Ste 240
Rome, GA 30165-2042

Phone

(706) 368-8575

Fax

(706) 204-9430

NPI assigned

Jan 23, 2008

Last updated

Apr 16, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Ms. Bethany Jean Wall Former name

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: bjackson2336839@adventhealth.direct-ci.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Adventist Health System Georgia Inc

  dba AdventHealth Medical Group

  • Multi-Specialty Clinic/Center
  • Calhoun, GA
  • NPI 1699791343
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1201046400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1713225600000",
    "number": "1033396841",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 12938",
            "address_2": "C/O CLINIC MANAGEMENT",
            "city": "CALHOUN",
            "state": "GA",
            "postal_code": "30703",
            "telephone_number": "706-602-7800"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2112 SHORTER AVE NW STE 240",
            "city": "ROME",
            "state": "GA",
            "postal_code": "301652042",
            "telephone_number": "706-368-8575",
            "fax_number": "706-204-9430"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "BETHANY",
        "middle_name": "WALL",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2008-01-23",
        "last_updated": "2024-04-16",
        "certification_date": "2024-04-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "GA",
            "license": "060642",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "BETHANY",
            "last_name": "WALL",
            "middle_name": "JEAN",
            "prefix": "MS.",
            "credential": "P.A.-C.",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Michael Isley, MD
• Oluwagbemisola Francisca Israel, MD
• Stevie Ann Ivey, FNP-C
• J Keith Fricks Counseling LLC
• Aloysius Jackson, MD
• Charles Frederick Jackson III, M.D.
• Cline Thomas Jackson, M.D.
• Kelsea Artesse Jackson
• Lethecia Jackson, MPT
• Michael S Jackson, MD

• Pediatrics Physician in Rome, GA
• Providers in Rome, GA by specialty
• Pediatrics Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 16, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.