Healthcare Provider Details

I. General information

NPI: 1124526280
Provider Name (Legal Business Name): SHANNON JACKSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 INDEPENDENCE AVE
AKRON OH
44310-2541
US

IV. Provider business mailing address

850 INDEPENDENCE AVE
AKRON OH
44310-2541
US

V. Phone/Fax

Practice location:
  • Phone: 330-766-8277
  • Fax:
Mailing address:
  • Phone: 330-766-8277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN.CNP.020775
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN.CNP.020775
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.020775
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: