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General NPI Number Information
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NPI Number | 1801779079
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Entity Type | Individual
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Provider Name | SHARONDA JACKSON
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Gender | Female
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Dates
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Enumeration Date | 07/28/2025
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Last Update Date | 07/28/2025
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Provider Practice Location Address
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Address Line | 192 KACEY LN
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City | WAVELAND
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State | MS
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Zip | 39576-2540
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Country | US
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Telephone | 228-343-1945
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Fax |
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Provider Business Mailing Address
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Address Line | 192 KACEY LN
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City | WAVELAND
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State | MS
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Zip | 39576-2540
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Country | US
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Telephone | 228-343-1945
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 907616
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License Number State | MS
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