Healthcare Provider Details

I. General information

NPI: 1861237257
Provider Name (Legal Business Name): SHELBY JACKSON LPCMH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W MAIN ST
MIDDLETOWN DE
19709-1040
US

IV. Provider business mailing address

120 W MAIN ST
MIDDLETOWN DE
19709-1040
US

V. Phone/Fax

Practice location:
  • Phone: 302-272-9845
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: