Provider Demographics
NPI:1851281851
Name:JACKSON, SHELITA RENEE
Entity type:Individual
Prefix:
First Name:SHELITA
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 AVALON DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-1738
Mailing Address - Country:US
Mailing Address - Phone:502-644-0002
Mailing Address - Fax:
Practice Address - Street 1:2420 AVALON DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-1738
Practice Address - Country:US
Practice Address - Phone:502-644-0002
Practice Address - Fax:502-644-0002
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-09
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50203414251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health