Provider Demographics
NPI:1730786641
Name:JACKSON, SHANA LORENE COX (CPNP-PC)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:LORENE COX
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 CENTRE SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-6319
Mailing Address - Country:US
Mailing Address - Phone:803-642-9204
Mailing Address - Fax:
Practice Address - Street 1:206 CENTRE SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-6319
Practice Address - Country:US
Practice Address - Phone:803-642-9204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-04
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC231529163WP0200X
SC25500363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics