Provider Demographics
NPI:1508652678
Name:JACKSON, SHELBY L (CHW)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5600
Mailing Address - Country:US
Mailing Address - Phone:505-397-5172
Mailing Address - Fax:505-397-5172
Practice Address - Street 1:2111 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5600
Practice Address - Country:US
Practice Address - Phone:505-397-5172
Practice Address - Fax:505-397-5172
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0018-2025374J00000X
NMS1-1776172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty