Provider Demographics
NPI:1811323645
Name:JACKSON-WILLIAMS, SHANNON DENISE (APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DENISE
Last Name:JACKSON-WILLIAMS
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:DENISE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:239 DIANE LN
Mailing Address - Street 2:
Mailing Address - City:STONEWALL
Mailing Address - State:LA
Mailing Address - Zip Code:71078-9507
Mailing Address - Country:US
Mailing Address - Phone:318-235-7554
Mailing Address - Fax:
Practice Address - Street 1:8932 JEWELLA AVE STE A
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2117
Practice Address - Country:US
Practice Address - Phone:318-219-4167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX801526363L00000X
LAAP07433363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner