Provider Demographics
NPI:1053197392
Name:JACKSON, SHANTENY
Entity type:Individual
Prefix:
First Name:SHANTENY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 GRAYFOX DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-5667
Mailing Address - Country:US
Mailing Address - Phone:804-306-3096
Mailing Address - Fax:
Practice Address - Street 1:1717 E CARY ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-7024
Practice Address - Country:US
Practice Address - Phone:804-306-3096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-04
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2325374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula