Healthcare Provider Details

I. General information

NPI: 1891524799
Provider Name (Legal Business Name): IEACHA SHAHARA JACKSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 CHURCH ST
RICHLAND GA
31825-6210
US

IV. Provider business mailing address

PO BOX 291
RICHLAND GA
31825-0291
US

V. Phone/Fax

Practice location:
  • Phone: 229-449-1289
  • Fax:
Mailing address:
  • Phone: 229-449-1289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF07241421
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: