Healthcare Provider Details

I. General information

NPI: 1528360948
Provider Name (Legal Business Name): SHONDA RENNE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 WOODLAND AVE
PLAINFIELD NJ
07060-3362
US

IV. Provider business mailing address

563 E FRONT ST APT B
PLAINFIELD NJ
07060-1411
US

V. Phone/Fax

Practice location:
  • Phone: 908-753-1113
  • Fax:
Mailing address:
  • Phone: 908-561-0762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA46TA09032200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: