Healthcare Provider Details

I. General information

NPI: 1902549405
Provider Name (Legal Business Name): SHAUNTAY JACKSON LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2541 OLINVILLE AVE APT 4B
BRONX NY
10467-7491
US

IV. Provider business mailing address

2541 OLINVILLE AVE APT 4B
BRONX NY
10467-7491
US

V. Phone/Fax

Practice location:
  • Phone: 347-318-7140
  • Fax:
Mailing address:
  • Phone: 347-318-7140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number002627-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: