Provider Demographics
NPI:1598289779
Name:JACKSON-UMEH, SHONETTE RENA
Entity Type:Individual
Prefix:
First Name:SHONETTE
Middle Name:RENA
Last Name:JACKSON-UMEH
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 1:7306 EDEN CROSSING LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-1574
Mailing Address - Country:US
Mailing Address - Phone:832-258-2808
Mailing Address - Fax:
Practice Address - Street 1:7306 EDEN CROSSING LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-1574
Practice Address - Country:US
Practice Address - Phone:832-258-2808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TX13653101YA0400X
TX74628101Y00000X, 101YM0800X, 405300000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1528574282Medicaid