Provider Demographics
NPI:1851910897
Name:JACKSON, SHONTAY (CPT)
Entity Type:Individual
Prefix:MRS
First Name:SHONTAY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:SHONTAY
Other - Middle Name:
Other - Last Name:ACKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:198 N MCDONOUGH ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-3665
Mailing Address - Country:US
Mailing Address - Phone:888-484-6776
Mailing Address - Fax:
Practice Address - Street 1:4600 ROCKBRIDGE RD STE A
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-7312
Practice Address - Country:US
Practice Address - Phone:888-484-6776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA448156146N00000X
GAF07191809363LF0000X
246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA668-26-9957OtherFAMILY PRACTICE