Provider Demographics
NPI:1982317764
Name:JACKSON, SHACARYA KATORIA (APRN)
Entity type:Individual
Prefix:
First Name:SHACARYA
Middle Name:KATORIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 CHERRY ST STE A
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2880
Mailing Address - Country:US
Mailing Address - Phone:478-297-0238
Mailing Address - Fax:478-314-7868
Practice Address - Street 1:617 CHERRY ST STE A
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2880
Practice Address - Country:US
Practice Address - Phone:478-297-0238
Practice Address - Fax:478-314-7868
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN254432363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health