Provider Demographics
NPI:1063009645
Name:SHORTER, JERMAINE
Entity Type:Individual
Prefix:
First Name:JERMAINE
Middle Name:
Last Name:SHORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 LYNNFIELD ROAD
Mailing Address - Street 2:STE. 270
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119
Mailing Address - Country:US
Mailing Address - Phone:901-568-6397
Mailing Address - Fax:
Practice Address - Street 1:1355 LYNNFIELD ROAD
Practice Address - Street 2:STE. 270
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119
Practice Address - Country:US
Practice Address - Phone:901-568-6397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5134101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health