Provider Demographics
NPI:1891394102
Name:JACKSON, SHAUNDA LYNN
Entity Type:Individual
Prefix:
First Name:SHAUNDA
Middle Name:LYNN
Last Name:JACKSON
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 1:19250 W LAKE HOUSTON PKWY
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-2279
Mailing Address - Country:US
Mailing Address - Phone:281-541-6265
Mailing Address - Fax:
Practice Address - Street 1:19250 W LAKE HOUSTON PKWY
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-2279
Practice Address - Country:US
Practice Address - Phone:281-541-6265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341501835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist