Healthcare Provider Details

I. General information

NPI: 1508652678
Provider Name (Legal Business Name): SHELBY L JACKSON CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 COLLEGE DR
GALLUP NM
87301-5600
US

IV. Provider business mailing address

2111 COLLEGE DR
GALLUP NM
87301-5600
US

V. Phone/Fax

Practice location:
  • Phone: 505-397-5172
  • Fax: 505-397-5172
Mailing address:
  • Phone: 505-397-5172
  • Fax: 505-397-5172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number0018-2025
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberS1-1776
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: