Provider Demographics
NPI:1003105396
Name:JACKSON, SHEENA LENE (MSED)
Entity type:Individual
Prefix:
First Name:SHEENA
Middle Name:LENE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:SHEENA
Other - Middle Name:LENE
Other - Last Name:GIDRON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSED
Mailing Address - Street 1:1965 SCHIEFFELIN AVE
Mailing Address - Street 2:#1C
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-5614
Mailing Address - Country:US
Mailing Address - Phone:718-515-9273
Mailing Address - Fax:718-515-9273
Practice Address - Street 1:1965 SCHIEFFELIN AVE
Practice Address - Street 2:#1C
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-5614
Practice Address - Country:US
Practice Address - Phone:718-515-9273
Practice Address - Fax:718-515-9273
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist