Provider Demographics
NPI:1194271502
Name:JACKSON, SHEENA N
Entity type:Individual
Prefix:
First Name:SHEENA
Middle Name:N
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 1:303 WHITE DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-7536
Mailing Address - Country:US
Mailing Address - Phone:270-799-8662
Mailing Address - Fax:
Practice Address - Street 1:303 WHITE DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101
Practice Address - Country:US
Practice Address - Phone:270-799-8662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-27
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201126652222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist