Healthcare Provider Details

I. General information

NPI: 1912858986
Provider Name (Legal Business Name): SHORTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2582 COURTNEY DR
MEMPHIS TN
38128-4702
US

IV. Provider business mailing address

2582 COURTNEY DR
MEMPHIS TN
38128-4702
US

V. Phone/Fax

Practice location:
  • Phone: 901-830-9147
  • Fax:
Mailing address:
  • Phone: 901-830-9147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JERMAINE SHORTER
Title or Position: OFFICER
Credential: LPC-MHSP
Phone: 901-830-9147