MEDICARE: MS. SHAWNDA TRENAY JACKSON LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN.118913	OH

General Provider Information

NPI Number	:	1518163716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHAWNDA TRENAY JACKSON LPN

Provider Business Mailing Address
First Line	:	5343 CLEMENT AVENUE
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137
Country	:	US
Telephone Number	:	216-663-2430
Fax Number	:

Provider Business Practice Location Address
First Line	:	5343 CLEMENT AVE
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-2605
Country	:	US
Telephone Number	:	216-663-2430
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	07/08/2007

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