Provider Demographics
NPI:1326077785
Name:SHACKELFORD, JAMES HUBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:HUBERT
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 S MILWAUKEE AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3759
Mailing Address - Country:US
Mailing Address - Phone:847-367-5991
Mailing Address - Fax:847-367-5997
Practice Address - Street 1:1113 S MILWAUKEE AVE
Practice Address - Street 2:STE 104
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3758
Practice Address - Country:US
Practice Address - Phone:847-367-5991
Practice Address - Fax:847-367-5997
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071002782103T00000X, 103TC0700X
IL24159101YA0400X
IL166000265106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid