MEDICARE: SHONNESHIA JACKSON

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1922472075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHONNESHIA JACKSON

Provider Business Mailing Address
First Line	:	820 S POLK AVE
Second Line	:
City	:	JONESBORO
State	:	LA
Zip	:	71251-3714
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	820 S POLK AVE
Second Line	:
City	:	JONESBORO
State	:	LA
Zip	:	71251-3714
Country	:	US
Telephone Number	:	318-475-2479
Fax Number	:

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

Provider Enumeration Date	:	11/29/2015
Last Update Date	:	11/29/2015

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Directions to “ SHONNESHIA JACKSON ” Practice Location

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