Provider Demographics
NPI:1255674453
Name:JACKSON, SHANQUAN (BA)
Entity Type:Individual
Prefix:MS
First Name:SHANQUAN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10950 SW 222ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33170-6553
Mailing Address - Country:US
Mailing Address - Phone:786-973-4843
Mailing Address - Fax:
Practice Address - Street 1:9780 E INDIGO ST
Practice Address - Street 2:SUITE 302
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-5609
Practice Address - Country:US
Practice Address - Phone:305-232-6005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-05
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health