Provider Demographics
NPI:1124526280
Name:JACKSON, SHANNON (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44310-2541
Mailing Address - Country:US
Mailing Address - Phone:330-766-8277
Mailing Address - Fax:
Practice Address - Street 1:850 INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44310-2541
Practice Address - Country:US
Practice Address - Phone:330-766-8277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.020775363LA2200X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty