Provider Demographics
NPI:1982594313
Name:JACKSON, SHANTE OCTAVIA (LPN)
Entity type:Individual
Prefix:
First Name:SHANTE
Middle Name:OCTAVIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 E WILLOW GROVE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-3464
Mailing Address - Country:US
Mailing Address - Phone:856-514-0073
Mailing Address - Fax:
Practice Address - Street 1:50 E WILLOW GROVE AVE APT 1
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19118-3464
Practice Address - Country:US
Practice Address - Phone:856-514-0073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PALPN303611251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health