Provider Demographics
NPI:1679098347
Name:JACKSON, SHELLEY ANN (PHD, LCMHC)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 HATHAWAY PT. RD.
Mailing Address - Street 2:
Mailing Address - City:ST. ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-7200
Mailing Address - Country:US
Mailing Address - Phone:940-641-4186
Mailing Address - Fax:
Practice Address - Street 1:228 HATHAWAY PT. RD.
Practice Address - Street 2:
Practice Address - City:ST. ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478
Practice Address - Country:US
Practice Address - Phone:940-641-4186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1679098347101YM0800X
TX15616101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15616OtherLICENSED PROFESSIONAL COUNSELOR