Healthcare Provider Details

I. General information

NPI: 1013872597
Provider Name (Legal Business Name): AISHA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 FORT HILL ST
MACON GA
31217-3765
US

IV. Provider business mailing address

745 FORT HILL ST
MACON GA
31217-3765
US

V. Phone/Fax

Practice location:
  • Phone: 478-550-8597
  • Fax:
Mailing address:
  • Phone: 478-550-8597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License NumberCN0014188281
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: