Provider Demographics
NPI:1477258564
Name:JACKSON, SHAWNDRYA
Entity type:Individual
Prefix:MS
First Name:SHAWNDRYA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3787 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-5247
Mailing Address - Country:US
Mailing Address - Phone:216-801-7016
Mailing Address - Fax:
Practice Address - Street 1:3787 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5247
Practice Address - Country:US
Practice Address - Phone:216-801-7016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN510763163W00000X
172A00000X, 246RP1900X, 251X00000X, 332U00000X, 343900000X, 253Z00000X, 347C00000X, 376J00000X, 385H00000X, 251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No163W00000XNursing Service ProvidersRegistered Nurse
No172A00000XOther Service ProvidersDriver
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No251X00000XAgenciesSupports Brokerage
No332U00000XSuppliersHome Delivered Meals
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care