Provider Demographics
NPI:1962034389
Name:JACKSON, SHEENA ANNIECE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:SHEENA
Middle Name:ANNIECE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:SHEENA
Other - Middle Name:ANNIECE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6913 DIAMOND RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-7697
Mailing Address - Country:US
Mailing Address - Phone:314-532-6792
Mailing Address - Fax:
Practice Address - Street 1:18511 HIGHLANDER MEDICS ST
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79906-5327
Practice Address - Country:US
Practice Address - Phone:915-742-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1048628367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered