Provider Demographics
NPI:1750782561
Name:SHACKLETT, JONATHAN (MA, LPC, CAADC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SHACKLETT
Suffix:
Gender:M
Credentials:MA, LPC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S ANGLE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT JOY
Mailing Address - State:PA
Mailing Address - Zip Code:17552-2031
Mailing Address - Country:US
Mailing Address - Phone:717-653-1507
Mailing Address - Fax:
Practice Address - Street 1:410 S ANGLE ST
Practice Address - Street 2:
Practice Address - City:MOUNT JOY
Practice Address - State:PA
Practice Address - Zip Code:17552-2031
Practice Address - Country:US
Practice Address - Phone:717-653-1507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007789101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional