Healthcare Provider Details

I. General information

NPI: 1417875469
Provider Name (Legal Business Name): MARIA SHAUNTEE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 398
WAYCROSS GA
31502-0398
US

IV. Provider business mailing address

PO BOX 398
WAYCROSS GA
31502-0398
US

V. Phone/Fax

Practice location:
  • Phone: 912-614-8131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP180801
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: