Healthcare Provider Details

I. General information

NPI: 1740922657
Provider Name (Legal Business Name): JEFFREY JEROME SHIELDS LMHCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 160TH ST S
SPANAWAY WA
98387-8508
US

IV. Provider business mailing address

608 167TH CT E #3
SPANAWAY WA
98387-8508
US

V. Phone/Fax

Practice location:
  • Phone: 253-316-2060
  • Fax:
Mailing address:
  • Phone: 360-975-1313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC61436144
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: