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1922173897 NPI number — SHANE MICHELL JACKSON LPC

NPI Number: 1922173897
Health Care Provider/Practitioner: SHANE MICHELL JACKSON LPC

Information about “1922173897” NPI (SHANE MICHELL JACKSON LPC) exists in 1922173897 in HTML format HTML  |  1922173897 in plain Text format TXT  |  1922173897 in PDF (Portable Document Format) PDF  |  1922173897 in an XML format XML  formats.

NPI Number : 1922173897 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1922173897",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "JACKSON",
    "FirstName": "SHANE",
    "MiddleName": "MICHELL",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "LPC",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "PO BOX 1551",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "GILMER",
    "MailingAddressStateName": "TX",
    "MailingAddressPostalCode": "75644-1551",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "903-746-7643",
    "MailingAddressFaxNumber": "903-843-4336",
    "FirstLinePracticeLocationAddress": "115 W TYLER ST",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "GILMER",
    "PracticeLocationAddressStateName": "TX",
    "PracticeLocationAddressPostalCode": "75644-2239",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "903-746-7643",
    "PracticeLocationAddressFaxNumber": "903-843-4336",
    "EnumerationDate": "11/22/2006",
    "LastUpdateDate": "09/11/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "101YA0400X",
          "TaxonomyName": "Addiction (Substance Use Disorder) Counselor",
          "LicenseNumber": "4128",
          "LicenseNumberStateCode": "TX",
          "PrimaryTaxonomySwitch": "Y"
        },
        {
          "TaxonomyCode": "101YM0800X",
          "TaxonomyName": "Mental Health Counselor",
          "LicenseNumber": "16480",
          "LicenseNumberStateCode": "TX",
          "PrimaryTaxonomySwitch": "N"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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