Provider Demographics
NPI:1053051292
Name:JACKSON, SHANNON (RN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 W SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90220-1923
Mailing Address - Country:US
Mailing Address - Phone:562-338-6087
Mailing Address - Fax:
Practice Address - Street 1:618 W SCHOOL ST
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-1923
Practice Address - Country:US
Practice Address - Phone:310-933-8253
Practice Address - Fax:562-600-7803
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA482450171M00000X, 171400000X, 174H00000X, 405300000X, 163WC1600X, 101YM0800X, 163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171400000XOther Service ProvidersHealth & Wellness Coach
No174H00000XOther Service ProvidersHealth Educator
No405300000XOther Service ProvidersPrevention Professional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator