Healthcare Provider Details

I. General information

NPI: 1285598078
Provider Name (Legal Business Name): CHRISTANCIA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 BLACK BEAR TRL
DOUGLASVILLE GA
30135-5832
US

IV. Provider business mailing address

5200 BLACK BEAR TRL
DOUGLASVILLE GA
30135-5832
US

V. Phone/Fax

Practice location:
  • Phone: 404-980-0313
  • Fax:
Mailing address:
  • Phone: 404-980-0313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberCN0030057044
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: