Provider Demographics
NPI:1215413406
Name:CRAWFORD JACKSON, SHELLEY ANN (MS, LMHCA, CAAR)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ANN
Last Name:CRAWFORD JACKSON
Suffix:
Gender:F
Credentials:MS, LMHCA, CAAR
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:921 14TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:921 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2316
Practice Address - Country:US
Practice Address - Phone:360-423-0203
Practice Address - Fax:360-423-2311
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61025530101Y00000X
WAMC60863741101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2104954Medicaid