Healthcare Provider Details

I. General information

NPI: 1578490207
Provider Name (Legal Business Name): SHANIKA JANIELLE RUCKER MBA, BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 E MAIN ST
PRINCETON WV
24740-3002
US

IV. Provider business mailing address

1428 E MAIN ST
PRINCETON WV
24740-3002
US

V. Phone/Fax

Practice location:
  • Phone: 304-425-9541
  • Fax: 681-282-5558
Mailing address:
  • Phone: 304-425-9541
  • Fax: 681-282-5558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: