Provider Demographics
NPI:1275257172
Name:JACKSON, SHONDA LAFAYE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SHONDA
Middle Name:LAFAYE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 WEBER ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:LA
Mailing Address - Zip Code:70538-4124
Mailing Address - Country:US
Mailing Address - Phone:337-828-2550
Mailing Address - Fax:337-355-2333
Practice Address - Street 1:1115 WEBER ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:LA
Practice Address - Zip Code:70538-4124
Practice Address - Country:US
Practice Address - Phone:337-828-2550
Practice Address - Fax:337-355-2333
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA227271363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health