Provider Demographics
NPI:1790499358
Name:SHORTER, JULIAN (PMHNP)
Entity Type:Individual
Prefix:
First Name:JULIAN
Middle Name:
Last Name:SHORTER
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15627
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-0627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 E DICKINSON ST
Practice Address - Street 2:
Practice Address - City:WOODSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08098-1316
Practice Address - Country:US
Practice Address - Phone:856-490-0643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61395571363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health