Individual
SHANTAY JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1954 MARABOU DR, DAVENPORT, FL 33896-8616
(407) 995-9094
Mailing address
1954 MARABOU DR, DAVENPORT, FL 33896-8616
(407) 717-6749
Taxonomy
Speciality
Code
Description
License number
State
376J00000X
Homemaker
Primary
422805
FL
Other
Enumeration date
07/25/2022
Last updated
07/25/2022
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