Provider Demographics
NPI:1285396531
Name:SHELTON, JAMAAL
Entity type:Individual
Prefix:
First Name:JAMAAL
Middle Name:
Last Name:SHELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 FORTINGALE CIR
Mailing Address - Street 2:
Mailing Address - City:SANDSTON
Mailing Address - State:VA
Mailing Address - Zip Code:23150-1001
Mailing Address - Country:US
Mailing Address - Phone:718-208-8349
Mailing Address - Fax:
Practice Address - Street 1:2907 MARIA DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-3003
Practice Address - Country:US
Practice Address - Phone:718-208-8349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YM0800X
VA1434251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health