Provider Demographics
NPI:1740527100
Name:SHACKELFORD, JO (EDD, CCC-SLP)
Entity type:Individual
Prefix:DR
First Name:JO
Middle Name:
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:EDD, CCC-SLP
Other - Prefix:
Other - First Name:JO
Other - Middle Name:
Other - Last Name:MCELROY FITZHERBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1133 CHESTNUT ST., #3
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101
Mailing Address - Country:US
Mailing Address - Phone:270-202-3316
Mailing Address - Fax:
Practice Address - Street 1:1918 MOSSWOOD DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-4550
Practice Address - Country:US
Practice Address - Phone:270-202-3316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2020-02-26
Deactivation Date:2018-04-16
Deactivation Code:
Reactivation Date:2020-02-26
Provider Licenses
StateLicense IDTaxonomies
KY1374235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist