Provider Demographics
NPI:1851842843
Name:JACKSON, SHANNON REGINA (NP-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:REGINA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 GENTILLY BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70122-3854
Mailing Address - Country:US
Mailing Address - Phone:504-383-0599
Mailing Address - Fax:504-383-0594
Practice Address - Street 1:3100 GENTILLY BLVD
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70122-3854
Practice Address - Country:US
Practice Address - Phone:504-383-0599
Practice Address - Fax:504-383-0594
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09036363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily