Provider Demographics
NPI:1538505003
Name:JACKSON, SHEKINAH R (LPN)
Entity Type:Individual
Prefix:
First Name:SHEKINAH
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3083 KINGSBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-1627
Mailing Address - Country:US
Mailing Address - Phone:315-254-3910
Mailing Address - Fax:315-234-5915
Practice Address - Street 1:3083 KINGSBRIDGE LN
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-1627
Practice Address - Country:US
Practice Address - Phone:315-254-3910
Practice Address - Fax:315-234-5915
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219014164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse