Provider Demographics
NPI:1811103468
Name:SHORTRIDGE, JACK L (EDD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:L
Last Name:SHORTRIDGE
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W SHEPARD LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-4242
Mailing Address - Country:US
Mailing Address - Phone:843-821-0323
Mailing Address - Fax:
Practice Address - Street 1:5300 INTERNATIONAL BLVD
Practice Address - Street 2:WEBSTER UNIVERSITY
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-6937
Practice Address - Country:US
Practice Address - Phone:843-760-1324
Practice Address - Fax:843-760-1153
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-178103TC1900X
SC1213106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist