Healthcare Provider Details

I. General information

NPI: 1457766685
Provider Name (Legal Business Name): MRS. HARRIET SHUNTA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 06/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 WHITE AVE
NASHVILLE TN
37204-2235
US

IV. Provider business mailing address

2400 WHITE AVE
NASHVILLE TN
37204-2235
US

V. Phone/Fax

Practice location:
  • Phone: 615-460-4120
  • Fax: 615-460-4202
Mailing address:
  • Phone: 615-460-4120
  • Fax: 615-460-4202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: