Provider Demographics
NPI:1073045050
Name:JACKSON, SHANETTE
Entity type:Individual
Prefix:
First Name:SHANETTE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10672 KENAI SPUR HWY STE 112
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7868
Mailing Address - Country:US
Mailing Address - Phone:907-513-2467
Mailing Address - Fax:
Practice Address - Street 1:602 FRONTAGE ROAD, STE.206
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611
Practice Address - Country:US
Practice Address - Phone:907-416-8276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK128047225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist