Healthcare Provider Details

I. General information

NPI: 1982186847
Provider Name (Legal Business Name): KRISA FOREHAND JACKSON ATC, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 GA HIGHWAY 57
MACON GA
31217-2803
US

IV. Provider business mailing address

442 GA HIGHWAY 57
MACON GA
31217-2803
US

V. Phone/Fax

Practice location:
  • Phone: 478-550-0212
  • Fax:
Mailing address:
  • Phone: 478-550-0212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003814
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13715
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: