Provider Demographics
NPI:1346056660
Name:JACKSON, SHADIA (CFA)
Entity type:Individual
Prefix:
First Name:SHADIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9333 SAINT LEGER PL
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-5474
Mailing Address - Country:US
Mailing Address - Phone:813-952-4957
Mailing Address - Fax:
Practice Address - Street 1:2600 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-9207
Practice Address - Country:US
Practice Address - Phone:813-952-4957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL189828207X00000X, 208600000X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery