Provider Demographics
NPI:1326387671
Name:GANTT, SHAKESHA P
Entity Type:Individual
Prefix:
First Name:SHAKESHA
Middle Name:P
Last Name:GANTT
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 1:7101 WILSON BLVD
Mailing Address - Street 2:#4304
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-3685
Mailing Address - Country:US
Mailing Address - Phone:904-781-7797
Mailing Address - Fax:
Practice Address - Street 1:2392 EDGEWOOD AVE N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-1725
Practice Address - Country:US
Practice Address - Phone:904-781-7797
Practice Address - Fax:904-854-0504
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator