Individual
SHAVONTA JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
CNA
Contact information
Practice address
1607 BARRINGTON VW, STONE MOUNTAIN, GA 30087-1846
(678) 582-9317
Mailing address
1607 BARRINGTON VW, STONE MOUNTAIN, GA 30087-1846
(678) 582-9317
Taxonomy
Speciality
Code
Description
License number
State
376K00000X
Nurse's Aide
Primary
CN0028901061
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
9576376
CIGNA HEALTHCARE
GA
Enumeration date
04/23/2022
Last updated
04/23/2022
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