Provider Demographics
NPI:1255181442
Name:JACKSON, SHYNETRA
Entity type:Individual
Prefix:
First Name:SHYNETRA
Middle Name:
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 1:4679 MARCOS CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-2743
Mailing Address - Country:US
Mailing Address - Phone:407-259-6984
Mailing Address - Fax:
Practice Address - Street 1:4679 MARCOS CIR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34758-2743
Practice Address - Country:US
Practice Address - Phone:407-259-6984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11031964363LP0808X
FL$$$$$$$$$363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health