Provider Demographics
NPI:1033129010
Name:JACKSON, SHELLI SHULTZ (PHD)
Entity Type:Individual
Prefix:DR
First Name:SHELLI
Middle Name:SHULTZ
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 BOARDWALK STE 203
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6593
Mailing Address - Country:US
Mailing Address - Phone:405-329-8501
Mailing Address - Fax:405-253-0581
Practice Address - Street 1:2500 BOARDWALK STE 203
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6593
Practice Address - Country:US
Practice Address - Phone:405-329-8501
Practice Address - Fax:405-253-0581
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK922103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100839280AMedicaid
OK100839280AMedicaid