Provider Demographics
NPI:1205215654
Name:SHACKELFORD, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:SHACKELFORD
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 1:97346 BLUFF VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-1917
Mailing Address - Country:US
Mailing Address - Phone:904-945-7867
Mailing Address - Fax:
Practice Address - Street 1:1100 CESERY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5674
Practice Address - Country:US
Practice Address - Phone:904-333-7927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3360106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist