Healthcare Provider Details

I. General information

NPI: 1851842843
Provider Name (Legal Business Name): SHANNON REGINA JACKSON NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date: 10/10/2025
Reactivation Date: 10/29/2025

III. Provider practice location address

101 ELLIOTT AVE W STE 500
SEATTLE WA
98119-4292
US

IV. Provider business mailing address

600 1ST AVE
SEATTLE WA
98104-2210
US

V. Phone/Fax

Practice location:
  • Phone: 206-708-6432
  • Fax:
Mailing address:
  • Phone: 504-505-6860
  • Fax: 504-233-7684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP09036
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP09036
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61640256
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: