Provider Demographics
NPI:1215757265
Name:SHINALL, JACQUELINE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:SHINALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 KRAMS AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-4730
Mailing Address - Country:US
Mailing Address - Phone:203-733-4298
Mailing Address - Fax:
Practice Address - Street 1:382 COCONUT CIR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3317
Practice Address - Country:US
Practice Address - Phone:203-733-4298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY12409103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical