Provider Demographics
NPI:1053818518
Name:JACKSON, SHAWNI
Entity Type:Individual
Prefix:
First Name:SHAWNI
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 1:3927 W 146TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-4322
Mailing Address - Country:US
Mailing Address - Phone:216-334-6377
Mailing Address - Fax:
Practice Address - Street 1:3100 E 45TH ST STE 314
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44127-1095
Practice Address - Country:US
Practice Address - Phone:216-441-9622
Practice Address - Fax:888-460-4717
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator