Provider Demographics
NPI:1093094617
Name:SHANKLIN, JARVIS GERARD (LCSW)
Entity Type:Individual
Prefix:
First Name:JARVIS
Middle Name:GERARD
Last Name:SHANKLIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5022
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5022
Mailing Address - Country:US
Mailing Address - Phone:985-413-2280
Mailing Address - Fax:
Practice Address - Street 1:3135 HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:RACELAND
Practice Address - State:LA
Practice Address - Zip Code:70394-3652
Practice Address - Country:US
Practice Address - Phone:985-413-2280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-13
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA60141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical