Provider Demographics
NPI:1033649751
Name:JACKSON, SHAMEEKA KENYON
Entity Type:Individual
Prefix:
First Name:SHAMEEKA
Middle Name:KENYON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-5215
Mailing Address - Country:US
Mailing Address - Phone:229-296-5020
Mailing Address - Fax:
Practice Address - Street 1:2102 OXFORD RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-5215
Practice Address - Country:US
Practice Address - Phone:229-296-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty