Provider Demographics
NPI:1720602527
Name:RAIKES, SHANNON E (MED, LMHC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:RAIKES
Suffix:
Gender:F
Credentials:MED, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13990 BARTRAM PARK BLVD UNIT 209
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5543
Mailing Address - Country:US
Mailing Address - Phone:214-551-5365
Mailing Address - Fax:
Practice Address - Street 1:13990 BARTRAM PARK BLVD UNIT 209
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5543
Practice Address - Country:US
Practice Address - Phone:214-551-5365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16624101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health