Healthcare Provider Details

I. General information

NPI: 1093631582
Provider Name (Legal Business Name): JAKORI BRYASIA WISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NORTHSIDE XING STE A
MACON GA
31210-2377
US

IV. Provider business mailing address

120 IGNICO DR APT K4
WARNER ROBINS GA
31093-8617
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 478-751-8828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: