Provider Demographics
NPI:1891267910
Name:JACKSON, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 N BERWICK CRES
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-2316
Mailing Address - Country:US
Mailing Address - Phone:916-479-4328
Mailing Address - Fax:
Practice Address - Street 1:4870 SADLER RD
Practice Address - Street 2:SUITE #300
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-6294
Practice Address - Country:US
Practice Address - Phone:916-479-4328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68-0396223Medicaid