Provider Demographics
NPI:1538218292
Name:JACKSON, SHIRLEY JEAN (RN)
Entity type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:JEAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13236 WYNSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-3254
Mailing Address - Country:US
Mailing Address - Phone:608-931-4477
Mailing Address - Fax:
Practice Address - Street 1:21 NORTH ATWOOD AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53648
Practice Address - Country:US
Practice Address - Phone:608-931-4477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39916200Medicaid