Provider Demographics
NPI:1316770274
Name:SHACKELFORD, JESSICA JULIA (PMHNP-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JULIA
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:PMHNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6366 BIG OAK RD
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-9048
Mailing Address - Country:US
Mailing Address - Phone:559-836-7159
Mailing Address - Fax:
Practice Address - Street 1:6366 BIG OAK RD
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:CA
Practice Address - Zip Code:93657-9048
Practice Address - Country:US
Practice Address - Phone:559-836-7159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-24
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95031821363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health