Healthcare Provider Details

I. General information

NPI: 1962565408
Provider Name (Legal Business Name): JAMES SHACKSON MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9525 KENWOOD RD SUITE 16-382
CINCINNATI OH
45242-6176
US

IV. Provider business mailing address

L 6122
CINCINNATI OH
45270-6122
US

V. Phone/Fax

Practice location:
  • Phone: 513-721-3504
  • Fax: 513-345-6281
Mailing address:
  • Phone: 513-721-3504
  • Fax: 513-345-6281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number35062208
License Number StateOH

VIII. Authorized Official

Name: DR. JAMES SHACKSON
Title or Position: PRESIDENT
Credential: MD
Phone: 513-721-3504