Healthcare Provider Details

I. General information

NPI: 1982594313
Provider Name (Legal Business Name): SHANTE OCTAVIA JACKSON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E WILLOW GROVE AVE APT 1
PHILA PA
19118-3464
US

IV. Provider business mailing address

50 E WILLOW GROVE AVE APT 1
PHILA PA
19118-3464
US

V. Phone/Fax

Practice location:
  • Phone: 856-514-0073
  • Fax:
Mailing address:
  • Phone: 856-514-0073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN303611
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: