MEDICARE: SHAMIKA JACKSON RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN290480	GA

General Provider Information

NPI Number	:	1639802291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAMIKA JACKSON RN

Provider Business Mailing Address
First Line	:	6740 SHANNON PKWY
Second Line	:	STE 9 #120
City	:	UNION CITY
State	:	GA
Zip	:	30291
Country	:	US
Telephone Number	:	404-917-9972
Fax Number	:

Provider Business Practice Location Address
First Line	:	3922 MAKEOVER CT
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-2794
Country	:	US
Telephone Number	:	404-917-9972
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2022
Last Update Date	:	07/01/2022

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