Provider Demographics
NPI:1811697303
Name:JACKSON, SHATEFFA
Entity type:Individual
Prefix:
First Name:SHATEFFA
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 1:730 EVANS ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1864
Mailing Address - Country:US
Mailing Address - Phone:347-425-2953
Mailing Address - Fax:
Practice Address - Street 1:730 EVANS ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1864
Practice Address - Country:US
Practice Address - Phone:347-425-2953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health