Provider Demographics
NPI: | 1922173897 |
---|---|
Name: | JACKSON, SHANE MICHELL (LPC) |
Entity Type: | Individual |
Prefix: | |
First Name: | SHANE |
Middle Name: | MICHELL |
Last Name: | JACKSON |
Suffix: | |
Gender: | F |
Credentials: | LPC |
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 1551 |
Mailing Address - Street 2: | |
Mailing Address - City: | GILMER |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75644-1551 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 903-746-7643 |
Mailing Address - Fax: | 903-843-4336 |
Practice Address - Street 1: | 115 W TYLER ST |
Practice Address - Street 2: | |
Practice Address - City: | GILMER |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75644-2239 |
Practice Address - Country: | US |
Practice Address - Phone: | 903-746-7643 |
Practice Address - Fax: | 903-843-4336 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-11-22 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 4128 | 101YA0400X |
TX | 16480 | 101YM0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
Not Answered | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 16480 | Other | LPC |
TX | 4128 | Other | LCDC |