Provider Demographics
NPI:1053854349
Name:WILSON, JANCEY SHELLNUTT (LPC)
Entity Type:Individual
Prefix:MS
First Name:JANCEY
Middle Name:SHELLNUTT
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:JANCEY
Other - Middle Name:SHELLNUTT
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:124 TYLER LN
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-1454
Mailing Address - Country:US
Mailing Address - Phone:706-647-7718
Mailing Address - Fax:
Practice Address - Street 1:124 TYLER LN
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-1454
Practice Address - Country:US
Practice Address - Phone:706-647-7718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008331101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional