Basic Information
Provider Information | |||||||||
NPI: | 1174800072 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JHA | ||||||||
FirstName: | SHASHANK | ||||||||
MiddleName: | KUMAR | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MBBS, FNP, PMHNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 445 WINN WAY | ||||||||
Address2: |   | ||||||||
City: | DECATUR | ||||||||
State: | GA | ||||||||
PostalCode: | 300301707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4045083835 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4255 WADE GREEN RD NW STE 414 | ||||||||
Address2: |   | ||||||||
City: | KENNESAW | ||||||||
State: | GA | ||||||||
PostalCode: | 301441763 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6782132194 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2011 | ||||||||
LastUpdateDate: | 01/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN214076 | GA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 17634 | SC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | RN214076 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | RN 214076 | 01 | GA | GEORGIA BOARD OF NURSING | OTHER | 17634 | 01 | SC | SOUTH CAROLINA BOARD OF NURSING | OTHER |