Provider Demographics
NPI:1407651243
Name:JACKSON, SHANICE B
Entity type:Individual
Prefix:
First Name:SHANICE
Middle Name:B
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 1:7935 N 154TH AVE
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:NE
Mailing Address - Zip Code:68007-1819
Mailing Address - Country:US
Mailing Address - Phone:402-250-9338
Mailing Address - Fax:
Practice Address - Street 1:4601 S 50TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68117-1355
Practice Address - Country:US
Practice Address - Phone:402-718-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide