Provider Demographics
NPI:1841822152
Name:JACKSON, SHELBY H
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:H
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:HELEN
Other - Last Name:PHELON-JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:504 CLINTON CENTER DRIVE
Mailing Address - Street 2:CBO-SUITE 4300
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39056
Mailing Address - Country:US
Mailing Address - Phone:601-496-9794
Mailing Address - Fax:601-815-0434
Practice Address - Street 1:960 AVENT DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5230
Practice Address - Country:US
Practice Address - Phone:662-227-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903610363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily