Provider Demographics
NPI:1992307870
Name:JACKSON, SHANTELL
Entity type:Individual
Prefix:
First Name:SHANTELL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 ROBINDALE ST
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-1843
Mailing Address - Country:US
Mailing Address - Phone:330-368-2617
Mailing Address - Fax:
Practice Address - Street 1:1834 ROBINDALE ST
Practice Address - Street 2:
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092-1843
Practice Address - Country:US
Practice Address - Phone:330-368-2617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-15
Last Update Date:2020-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4303862103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities