Provider Demographics
NPI:1821834474
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 1:4107 58TH PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39307-2925
Mailing Address - Country:US
Mailing Address - Phone:601-917-9830
Mailing Address - Fax:
Practice Address - Street 1:4107 58TH PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-2925
Practice Address - Country:US
Practice Address - Phone:601-917-9830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program