Provider Demographics
NPI:1629606264
Name:SHACKELFORD, JASMINE DONESHA (MD)
Entity Type:Individual
Prefix:MS
First Name:JASMINE
Middle Name:DONESHA
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 W GORDON ST
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3427
Mailing Address - Country:US
Mailing Address - Phone:706-647-7009
Mailing Address - Fax:
Practice Address - Street 1:915 W GORDON ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3427
Practice Address - Country:US
Practice Address - Phone:706-647-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA95589207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program