Provider Demographics
NPI:1235693441
Name:JACKSON, SHAKIA
Entity Type:Individual
Prefix:
First Name:SHAKIA
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 1:100 COPPER BEECH DR APT C
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-3194
Mailing Address - Country:US
Mailing Address - Phone:540-649-0780
Mailing Address - Fax:
Practice Address - Street 1:100 COPPER BEECH DR APT C
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-3194
Practice Address - Country:US
Practice Address - Phone:540-649-0780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program