Healthcare Provider Details

I. General information

NPI: 1578846598
Provider Name (Legal Business Name): SHANDA JACKSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANDA RICHARDSON FNP

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6569 HIGHWAY 84
FERRIDAY LA
71334-4573
US

IV. Provider business mailing address

PO BOX 1089
HAMMOND LA
70404-1089
US

V. Phone/Fax

Practice location:
  • Phone: 985-892-7070
  • Fax: 855-821-4499
Mailing address:
  • Phone: 985-892-7070
  • Fax: 985-892-7017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP06672
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR855819
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: