Provider Demographics
NPI:1821376344
Name:JACKSON, SHAETONNA MARIE (MSW-LSW)
Entity Type:Individual
Prefix:MS
First Name:SHAETONNA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW-LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 SIERRA VISTA DR
Mailing Address - Street 2:APT. 328
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-9387
Mailing Address - Country:US
Mailing Address - Phone:765-635-7698
Mailing Address - Fax:
Practice Address - Street 1:2820 W CHARLESTON BLVD
Practice Address - Street 2:C23
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1942
Practice Address - Country:US
Practice Address - Phone:702-437-4673
Practice Address - Fax:702-438-4673
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6011-S104100000X
NVIC-6911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker