Provider Demographics
NPI:1073045050
Name:JACKSON, SHANETTE
Entity Type:Individual
Prefix:
First Name:SHANETTE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35060 KENAI SPUR HWY
Mailing Address - Street 2:35060 KENAI SPUR HWY, SOLDOTNA, AK 99669
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7656
Mailing Address - Country:US
Mailing Address - Phone:907-420-4949
Mailing Address - Fax:
Practice Address - Street 1:35060 KENAI SPUR HWY
Practice Address - Street 2:35060 KENAI SPUR HWY, SOLDOTNA, AK 99669
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7656
Practice Address - Country:US
Practice Address - Phone:907-420-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1008236390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program