Provider Demographics
NPI:1265289078
Name:JACKSON, SHANNON M (CPRC, CCAR)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPRC, CCAR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3527
Mailing Address - Country:US
Mailing Address - Phone:810-422-9406
Mailing Address - Fax:810-733-7623
Practice Address - Street 1:1044 GILBERT ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3527
Practice Address - Country:US
Practice Address - Phone:810-422-9406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist