Healthcare Provider Details

I. General information

NPI: 1326077785
Provider Name (Legal Business Name): JAMES HUBERT SHACKELFORD PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 09/29/2026
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 S MILWAUKEE AVE STE 104
LIBERTYVILLE IL
60048-3758
US

IV. Provider business mailing address

1113 S MILWAUKEE AVE STE 104
LIBERTYVILLE IL
60048-3759
US

V. Phone/Fax

Practice location:
  • Phone: 847-367-5991
  • Fax: 847-367-5997
Mailing address:
  • Phone: 847-367-5991
  • Fax: 847-367-5997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24159
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071002782
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071002782
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166000265
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: