Provider Demographics
NPI:1386004745
Name:J&J SHINE CORP
Entity Type:Organization
Organization Name:J&J SHINE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANELL
Authorized Official - Middle Name:
Authorized Official - Last Name:STALLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:941-822-8174
Mailing Address - Street 1:8051 N. TAMIAMI TRAIL
Mailing Address - Street 2:SUITE E2, BOX 37
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243
Mailing Address - Country:US
Mailing Address - Phone:941-822-8174
Mailing Address - Fax:941-822-8174
Practice Address - Street 1:8051 N. TAMIAMI TRAIL
Practice Address - Street 2:SUITE E2, BOX 37
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243
Practice Address - Country:US
Practice Address - Phone:941-822-8174
Practice Address - Fax:941-822-8174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12905251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health