Provider Demographics
NPI:1225579428
Name:JACKSON, SHONDIA
Entity Type:Individual
Prefix:
First Name:SHONDIA
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 1:9137 MANSFIELD RD APT 104
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3143
Mailing Address - Country:US
Mailing Address - Phone:504-723-9795
Mailing Address - Fax:
Practice Address - Street 1:9137 MANSFIELD RD APT 104
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3143
Practice Address - Country:US
Practice Address - Phone:504-723-9795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker