Provider Demographics
NPI:1134616584
Name:JACKSON, SHANNON (PA-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 HOLY CROSS PKWY
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 E DOUGLAS RD STE 203
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1467
Practice Address - Country:US
Practice Address - Phone:574-335-6640
Practice Address - Fax:574-335-0621
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10005009A363A00000X
MI5601011128363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant