Provider Demographics
NPI:1770094005
Name:SHIVELEY, JACQUELYN ELIZABETH (LPC CDCA)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ELIZABETH
Last Name:SHIVELEY
Suffix:
Gender:F
Credentials:LPC CDCA
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 232
Mailing Address - Street 2:
Mailing Address - City:FRIENDSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45630-0232
Mailing Address - Country:US
Mailing Address - Phone:740-981-6419
Mailing Address - Fax:
Practice Address - Street 1:800 GALLIA ST STE 600
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4097
Practice Address - Country:US
Practice Address - Phone:740-353-4673
Practice Address - Fax:740-353-5800
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1700664101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional