Provider Demographics
NPI:1710506472
Name:JACKSON, SHANNA SHANEEN (NP)
Entity Type:Individual
Prefix:MS
First Name:SHANNA
Middle Name:SHANEEN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25315 MOORLAND RD
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-9277
Mailing Address - Country:US
Mailing Address - Phone:323-422-4640
Mailing Address - Fax:
Practice Address - Street 1:24060 FIR AVE STE A
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-2895
Practice Address - Country:US
Practice Address - Phone:951-247-8005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA755399163W00000X
CA95013739363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse