Provider Demographics
NPI:1386011344
Name:JACKSON, SHAWNA (NP)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1401 STEFFEN AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-2338
Mailing Address - Country:US
Mailing Address - Phone:513-588-3623
Mailing Address - Fax:513-554-4115
Practice Address - Street 1:8146 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45231-2324
Practice Address - Country:US
Practice Address - Phone:513-588-3623
Practice Address - Fax:513-728-4064
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP 17275363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0146004Medicaid
OHNP 17275OtherNP LICENSE
OHH431750Medicare PIN