Provider Demographics
NPI:1083037055
Name:JACKSON, SHAWNDREA
Entity Type:Individual
Prefix:
First Name:SHAWNDREA
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 1:9530 FLYING EAGLE CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-5183
Mailing Address - Country:US
Mailing Address - Phone:713-679-3592
Mailing Address - Fax:
Practice Address - Street 1:9530 FLYING EAGLE CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-5183
Practice Address - Country:US
Practice Address - Phone:713-679-3592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor