Healthcare Provider Details

I. General information

NPI: 1790601995
Provider Name (Legal Business Name): S. JACKSON PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 1ST ST
MACON GA
31201-2627
US

IV. Provider business mailing address

6711 CHRISWOOD DR
MACON GA
31216-6721
US

V. Phone/Fax

Practice location:
  • Phone: 478-216-3126
  • Fax:
Mailing address:
  • Phone: 478-216-3126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: SHACARYA JACKSON
Title or Position: OWNER
Credential: APRN
Phone: 478-216-3126