Provider Demographics
NPI:1477258564
Name:JACKSON, SHAWNDRYA
Entity Type:Individual
Prefix:
First Name:SHAWNDRYA
Middle Name:
Last Name:JACKSON
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 1:3359 W 100TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-1227
Mailing Address - Country:US
Mailing Address - Phone:216-801-7016
Mailing Address - Fax:
Practice Address - Street 1:3359 W 100TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-1227
Practice Address - Country:US
Practice Address - Phone:216-801-7016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246RP1900X, 332U00000X, 347C00000X, 172A00000X
OHRN510763163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No332U00000XSuppliersHome Delivered Meals
No347C00000XTransportation ServicesPrivate Vehicle
No172A00000XOther Service ProvidersDriver