Provider Demographics
NPI:1639806193
Name:JACKSON, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
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 1:2743 SMITH RANCH RD STE 704
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-5218
Mailing Address - Country:US
Mailing Address - Phone:281-215-3985
Mailing Address - Fax:
Practice Address - Street 1:2743 SMITH RANCH RD STE 704
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-5218
Practice Address - Country:US
Practice Address - Phone:281-215-3985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician