=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366262479
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMIAH JAMES SHELNUTT LPC-MHSP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2024
-----------------------------------------------------
Last Update Date | 10/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 VILLAGE DR
-----------------------------------------------------
City | GREENEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37745-4257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-278-4860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 BIRD CIR
-----------------------------------------------------
City | GREENEVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37743-4406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-278-4860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | LPC0000006618
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------