Provider Demographics
NPI:1851717649
Name:SHULTS, KENNETH JR (RN)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SHULTS
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2053 POWERS FERRY RD SE
Mailing Address - Street 2:APT. D
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-9675
Mailing Address - Country:US
Mailing Address - Phone:904-534-4725
Mailing Address - Fax:
Practice Address - Street 1:175 GWINNETT DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8444
Practice Address - Country:US
Practice Address - Phone:678-209-2394
Practice Address - Fax:678-212-6343
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health