Provider Demographics
NPI:1578846598
Name:JACKSON, SHANDA (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANDA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:SHANDA
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 1089
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-1089
Mailing Address - Country:US
Mailing Address - Phone:985-892-7070
Mailing Address - Fax:985-892-7017
Practice Address - Street 1:6569 HIGHWAY 84
Practice Address - Street 2:
Practice Address - City:FERRIDAY
Practice Address - State:LA
Practice Address - Zip Code:71334-4573
Practice Address - Country:US
Practice Address - Phone:985-892-7070
Practice Address - Fax:855-821-4499
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06672363LF0000X
MSR855819363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09503346Medicaid
LA2319248Medicaid
MSF0711469OtherCERTIFICATION NUMBER