Healthcare Provider Details

I. General information

NPI: 1609738731
Provider Name (Legal Business Name): JADEN TANISE SHIELDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9440 LEGENDS WAY, FORT HOOD
APO AA
76544
US

IV. Provider business mailing address

9440 LEGENDS WAY
FORT HOOD TX
76544
US

V. Phone/Fax

Practice location:
  • Phone: 254-288-7863
  • Fax:
Mailing address:
  • Phone: 254-288-7863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: