Healthcare Provider Details

I. General information

NPI: 1164353009
Provider Name (Legal Business Name): JACKSON HEART PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

1940 FOUNTAIN VIEW DR # 1282
HOUSTON TX
77057-3206
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: HUSAM SHADID
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 310-745-6830