Provider Demographics
NPI:1063668051
Name:JACKSON, SHINIECE NICOLE
Entity type:Individual
Prefix:MS
First Name:SHINIECE
Middle Name:NICOLE
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 1:5813 S SALINA ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205-3264
Mailing Address - Country:US
Mailing Address - Phone:315-380-4864
Mailing Address - Fax:
Practice Address - Street 1:5813 S SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-3264
Practice Address - Country:US
Practice Address - Phone:315-380-4864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-11
Last Update Date:2022-02-15
Deactivation Date:2011-11-01
Deactivation Code:
Reactivation Date:2022-02-15
Provider Licenses
StateLicense IDTaxonomies
NY263257-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse