Healthcare Provider Details

I. General information

NPI: 1730258708
Provider Name (Legal Business Name): SHAWN BARRETT JACKSON M,D,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PRIMROSE ST STE 550
SPRINGFIELD MO
65807-5180
US

IV. Provider business mailing address

1000 E PRIMROSE ST STE 550
SPRINGFIELD MO
65807-5180
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-4646
  • Fax:
Mailing address:
  • Phone: 417-269-4646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2005005716
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number2005005716
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: