MEDICARE: SHONTA JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1013511070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHONTA JACKSON

Provider Business Mailing Address
First Line	:	8301 PENCE RD APT B
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-4357
Country	:	US
Telephone Number	:	803-342-0553
Fax Number	:

Provider Business Practice Location Address
First Line	:	8301 PENCE RD APT B
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-4357
Country	:	US
Telephone Number	:	803-342-0553
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	11/30/2020

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Directions to “ SHONTA JACKSON ” Practice Location

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