Basic Information
| Provider Information | |||||||||
| NPI: | 1558456178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | SHARI | ||||||||
| MiddleName: | ALEENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCOTT-JACKSON | ||||||||
| OtherFirstName: | SHARI | ||||||||
| OtherMiddleName: | ALEENE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 218 E HOUSE ST | ||||||||
| Address2: | |||||||||
| City: | ALVIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775113544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818241480 | ||||||||
| FaxNumber: | 2812206407 | ||||||||
| Practice Location | |||||||||
| Address1: | 218 E HOUSE ST | ||||||||
| Address2: | |||||||||
| City: | ALVIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818241480 | ||||||||
| FaxNumber: | 2812206407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 11/30/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2006-01257 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | Q4434 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 363391901 | 05 | TX | MEDICAID | Q4434 | 01 | TX | MEDICAL LICENSE | OTHER |