Healthcare Provider Details

I. General information

NPI: 1215413406
Provider Name (Legal Business Name): SHELLEY ANN CRAWFORD JACKSON MS, LMHC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLEY CRAWFORD JACKSON

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 02/22/2025
Certification Date: 02/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13505 NE 10TH AVE
VANCOUVER WA
98685-2711
US

IV. Provider business mailing address

PO BOX 272
RIDGEFIELD WA
98642-0272
US

V. Phone/Fax

Practice location:
  • Phone: 503-284-1463
  • Fax:
Mailing address:
  • Phone: 360-284-1463
  • Fax: 360-326-7224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLH61025530
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC5800
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: