Provider Demographics
NPI:1003699661
Name:MACON, JASMAIN (FNP-BC)
Entity type:Individual
Prefix:
First Name:JASMAIN
Middle Name:
Last Name:MACON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6272 HICKORY LANE CIR
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-5507
Mailing Address - Country:US
Mailing Address - Phone:803-920-5895
Mailing Address - Fax:
Practice Address - Street 1:6272 HICKORY LANE CIR
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-5507
Practice Address - Country:US
Practice Address - Phone:803-920-5895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71015431A363LF0000X
MO2024030450363LF0000X
AR229320363LF0000X
FLAPRN11033675363LF0000X
NJ26NJ15159700363LF0000X
OH0036590363LF0000X
GAGAA-NP001528363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily