Healthcare Provider Details

I. General information

NPI: 1700701521
Provider Name (Legal Business Name): JACQUELINE SHULL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8108 N COMO DR
TUCSON AZ
85742-4207
US

IV. Provider business mailing address

8108 N COMO DR
TUCSON AZ
85742-4207
US

V. Phone/Fax

Practice location:
  • Phone: 201-788-2374
  • Fax:
Mailing address:
  • Phone: 201-788-2374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number44SC06110400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: