Provider Demographics
NPI:1427751312
Name:SHACKLETON, HAYLY JEAN (LSW)
Entity type:Individual
Prefix:
First Name:HAYLY
Middle Name:JEAN
Last Name:SHACKLETON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 98TH LN NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-1354
Mailing Address - Country:US
Mailing Address - Phone:612-817-0590
Mailing Address - Fax:
Practice Address - Street 1:7601 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1623
Practice Address - Country:US
Practice Address - Phone:612-223-8898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical