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General NPI Number Information
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NPI Number | 1205215654
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Entity Type | Individual
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Provider Name | ROBERT SHACKELFORD
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Gender | Male
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Dates
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Enumeration Date | 05/19/2015
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1100 CESERY BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32211-5674
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Country | US
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Telephone | 904-333-7927
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Fax |
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Provider Business Mailing Address
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Address Line | 97346 BLUFF VIEW CIR
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City | YULEE
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State | FL
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Zip | 32097-1917
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Country | US
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Telephone | 904-945-7867
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MT3360
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License Number State | FL
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