Healthcare Provider Details

I. General information

NPI: 1285560995
Provider Name (Legal Business Name): SHANNON JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8775 NORWIN AVE
IRWIN PA
15642-2718
US

IV. Provider business mailing address

622 ALLEGHENY RIVER BLVD APT 4
OAKMONT PA
15139-1554
US

V. Phone/Fax

Practice location:
  • Phone: 724-861-7920
  • Fax:
Mailing address:
  • Phone: 330-697-2952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT034232
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: