Provider Demographics
NPI:1982956108
Name:JACKSON, SHELIA SHENELL (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHELIA
Middle Name:SHENELL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7505 PINES RD
Mailing Address - Street 2:STE 1250
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-3935
Mailing Address - Country:US
Mailing Address - Phone:318-686-3770
Mailing Address - Fax:318-686-3838
Practice Address - Street 1:7505 PINES RD
Practice Address - Street 2:STE 1250
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-3935
Practice Address - Country:US
Practice Address - Phone:318-686-3770
Practice Address - Fax:318-686-3838
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LATAP002970363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily