Provider Demographics
NPI:1740761394
Name:JACKSON, SHONTA RENEA (LPN)
Entity type:Individual
Prefix:
First Name:SHONTA
Middle Name:RENEA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 GUN AND ROD RD
Mailing Address - Street 2:
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77833-5811
Mailing Address - Country:US
Mailing Address - Phone:713-265-8713
Mailing Address - Fax:713-665-9710
Practice Address - Street 1:1500 GUN AND ROD RD
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-5811
Practice Address - Country:US
Practice Address - Phone:713-265-8713
Practice Address - Fax:713-665-9710
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX206993164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse