Provider Demographics
NPI:1356011597
Name:JACKSON, CHANELL SHANNON (NMW, WHNP)
Entity Type:Individual
Prefix:
First Name:CHANELL
Middle Name:SHANNON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NMW, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5883 1/2 DOVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-7203
Mailing Address - Country:US
Mailing Address - Phone:310-848-7736
Mailing Address - Fax:
Practice Address - Street 1:5883 1/2 DOVERWOOD DR
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-7203
Practice Address - Country:US
Practice Address - Phone:310-848-7736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-19
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA236061363LW0102X, 176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health