Trevis Shantell Jackson

Primary specialty

Physical Medicine & Rehabilitation PhysicianTaxonomy code 208100000X

License

OTA000749 Issued in GA

Practice address

7420 Mistydawn Dr
Fairburn, GA 30213-4330

Phone

(678) 361-8944

NPI assigned

Dec 27, 2024

Last updated

Dec 27, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1735257600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1735257600000",
    "number": "1073321659",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7420 MISTYDAWN DR",
            "city": "FAIRBURN",
            "state": "GA",
            "postal_code": "302134330",
            "telephone_number": "678-361-8944"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7420 MISTYDAWN DR",
            "city": "FAIRBURN",
            "state": "GA",
            "postal_code": "302134330",
            "telephone_number": "678-361-8944"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "TREVIS",
        "middle_name": "SHANTELL",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-12-27",
        "last_updated": "2024-12-27",
        "certification_date": "2024-12-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208100000X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation",
            "state": "GA",
            "license": "OTA000749",
            "primary": true
        },
        {
            "code": "224Z00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapy Assistant",
            "state": "GA",
            "license": "OTA000749",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Terrell Humphries
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• Chemara Jackson, ED.D., LPC
• Jeane Watson DPM LLC
• Kendra Jenkins
• Jervon D Hamilton Counseling
• April Means Johnson, COTA/L
• Netoya Johnson, BSDH, RDH

• Physical Medicine & Rehabilitation Physician in Fairburn, GA
• Providers in Fairburn, GA by specialty
• Physical Medicine & Rehabilitation Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 27, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.