Provider Demographics
NPI:1790363588
Name:JACKSON, MAHKADA TAYLOR (PHD)
Entity type:Individual
Prefix:
First Name:MAHKADA
Middle Name:TAYLOR
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MAHKADA
Other - Middle Name:LYASHA
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1420 RIDGEBEND WAY SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126
Mailing Address - Country:US
Mailing Address - Phone:646-731-4785
Mailing Address - Fax:
Practice Address - Street 1:1420 RIDGEBEND WAY SE
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126
Practice Address - Country:US
Practice Address - Phone:646-731-4785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004135103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist