Provider Demographics
NPI:1568897783
Name:JACKSON, SHATONNE DIANNE (LPN)
Entity Type:Individual
Prefix:MS
First Name:SHATONNE
Middle Name:DIANNE
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 1:616 ELLSWORTHY DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45426
Mailing Address - Country:US
Mailing Address - Phone:937-581-5081
Mailing Address - Fax:
Practice Address - Street 1:616 ELLSWORTH DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426
Practice Address - Country:US
Practice Address - Phone:937-581-5081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH149943313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility