Provider Demographics
NPI:1952751729
Name:JACKSON, SHANTEL (LPC)
Entity type:Individual
Prefix:
First Name:SHANTEL
Middle Name:
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 1:2027 HEATHCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-3435
Mailing Address - Country:US
Mailing Address - Phone:330-559-9342
Mailing Address - Fax:
Practice Address - Street 1:1033 HIGH ST
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-4026
Practice Address - Country:US
Practice Address - Phone:614-885-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-13
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1800766101YP2500X
OHC.1000173101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health