Provider Demographics
NPI:1831081124
Name:JACKSON, SHERKEITH
Entity type:Individual
Prefix:
First Name:SHERKEITH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 GLOUCESTER ST STE 5
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-7145
Mailing Address - Country:US
Mailing Address - Phone:607-205-9186
Mailing Address - Fax:540-225-9700
Practice Address - Street 1:1606 GLOUCESTER ST STE 5
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-7145
Practice Address - Country:US
Practice Address - Phone:607-205-9186
Practice Address - Fax:540-225-9700
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-19
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23255663103TC0700X, 103TC2200X, 261QM0801X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No251B00000XAgenciesCase Management