MEDICARE: SHANTE OCTAVIA 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	251E00000X	Home Health Agency	LPN303611	PA

General Provider Information

NPI Number	:	1982594313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTE OCTAVIA JACKSON LPN

Provider Business Mailing Address
First Line	:	50 E WILLOW GROVE AVE APT 1
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19118-3464
Country	:	US
Telephone Number	:	856-514-0073
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 E WILLOW GROVE AVE APT 1
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19118-3464
Country	:	US
Telephone Number	:	856-514-0073
Fax Number	:

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

Provider Enumeration Date	:	07/07/2025
Last Update Date	:	07/07/2025

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