Healthcare Provider Details

I. General information

NPI: 1245677111
Provider Name (Legal Business Name): SHAUNDREAL DESERE'E JAMISON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2013
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MOYE BLVD
GREENVILLE NC
27834
US

IV. Provider business mailing address

PO BOX 751069
CHARLOTTE NC
28275-1069
US

V. Phone/Fax

Practice location:
  • Phone: 252-744-2335
  • Fax: 252-744-3811
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL35737
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2016-01611
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: