Individual
SHANNON JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
611 E DOUGLAS RD STE 203, MISHAWAKA, IN 46545-1467
(574) 335-6640
(574) 335-0621
Mailing address
5215 HOLY CROSS PKWY, MISHAWAKA, IN 46545-1469
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
10005009A
IN
363A00000X
Physician Assistant
5601011128
MI
Other
Enumeration date
04/20/2018
Last updated
10/14/2025
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