Provider Demographics
NPI:1467798553
Name:JACKSON, SHELLI M (CRNP)
Entity Type:Individual
Prefix:
First Name:SHELLI
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 WILMINGTON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16105-1538
Mailing Address - Country:US
Mailing Address - Phone:724-657-3204
Mailing Address - Fax:724-652-7144
Practice Address - Street 1:2602 WILMINGTON RD STE 200
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16105-1538
Practice Address - Country:US
Practice Address - Phone:724-657-3204
Practice Address - Fax:724-652-7144
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP012348363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care