Healthcare Provider Details

I. General information

NPI: 1689586729
Provider Name (Legal Business Name): SHONIECE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 CRAIG RD STE 127
SAINT LOUIS MO
63146-4767
US

IV. Provider business mailing address

702 BROADRIDGE LN APT 702
SAINT PETERS MO
63376-7508
US

V. Phone/Fax

Practice location:
  • Phone: 305-735-3878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: