Provider Demographics
NPI:1013186667
Name:SHELLEY, JACQUELINEB MARIE (LCSW-R,ACSW)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINEB
Middle Name:MARIE
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:LCSW-R,ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3505
Mailing Address - Country:US
Mailing Address - Phone:516-439-6527
Mailing Address - Fax:
Practice Address - Street 1:200 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3505
Practice Address - Country:US
Practice Address - Phone:516-439-6527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040315-1-R1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN362X1Medicare PIN