Provider Demographics
NPI:1730258708
Name:JACKSON, SHAWN BARRETT (M,D,)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:BARRETT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:M,D,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E PRIMROSE ST STE 550
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5180
Mailing Address - Country:US
Mailing Address - Phone:417-269-4646
Mailing Address - Fax:
Practice Address - Street 1:1000 E PRIMROSE ST STE 550
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5180
Practice Address - Country:US
Practice Address - Phone:417-269-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005005716207ZD0900X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO700100407Medicaid
MO1101160OtherUNITED HEALTHCARE
MO421539307OtherFED TAX ID-TRI-LAKES PATH
MO1559OtherBLUECROSSBLUESHIELD-PATHO
MO431451388OtherFED TAX ID-PATHOLOGY SERV
MO159012OtherBLUECROSSBLUESHIELD-TRI-L
MO705866705Medicaid
MOH97890Medicare UPIN
MO929333687Medicare ID - Type UnspecifiedMEDICARE-TRI-LAKES PATHOL
MO1559OtherBLUECROSSBLUESHIELD-PATHO
MO929333688Medicare ID - Type UnspecifiedMEDICARE-TRI-LAKES PATHOL
MO421539307OtherFED TAX ID-TRI-LAKES PATH
MOP00302935Medicare ID - Type UnspecifiedRAILROAD MEDICARE-TRI-LAK