Healthcare Provider Details

I. General information

NPI: 1053051292
Provider Name (Legal Business Name): SHANNON JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 W SCHOOL ST
COMPTON CA
90220-1923
US

IV. Provider business mailing address

618 W SCHOOL ST
COMPTON CA
90220-1923
US

V. Phone/Fax

Practice location:
  • Phone: 310-933-8253
  • Fax: 562-600-7803
Mailing address:
  • Phone: 562-338-6087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number482450
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number482450
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number482450
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number482450
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number482450
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number482450
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number482450
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: