MEDICARE: SHONETTE RENA JACKSON-UMEH

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	171M00000X	Case Manager/Care Coordinator
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	13653	TX
3	101Y00000X	Counselor	74628	TX
4	101YM0800X	Mental Health Counselor	74628	TX
5	405300000X	Prevention Professional	74628	TX
6	101YP2500X	Professional Counselor	74628	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598289779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHONETTE RENA JACKSON-UMEH

Provider Business Mailing Address
First Line	:	7306 EDEN CROSSING LN
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77407-1574
Country	:	US
Telephone Number	:	832-258-2808
Fax Number	:

Provider Business Practice Location Address
First Line	:	7306 EDEN CROSSING LN
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77407-1574
Country	:	US
Telephone Number	:	832-258-2808
Fax Number	:

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

Provider Enumeration Date	:	07/31/2017
Last Update Date	:	07/26/2022

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