MEDICARE: JANICE M. SHACKLETON, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	02228	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	02228	OTHER	GA	LPC

General Provider Information

NPI Number	:	1609259654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JANICE M. SHACKLETON, LPC

Provider Business Mailing Address
First Line	:	3400 PEACHTREE RD NE
Second Line	:	915
City	:	ATLANTA
State	:	GA
Zip	:	30326-1170
Country	:	US
Telephone Number	:	404-261-0772
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 PEACHTREE RD NE
Second Line	:	915
City	:	ATLANTA
State	:	GA
Zip	:	30326-1170
Country	:	US
Telephone Number	:	404-261-0772
Fax Number	:

Authorized Official
Title or Position	:	LPC
Name	:	JANICE SHACKLETON
Credential	:
Telephone Number	:	404-261-0772

Provider Enumeration Date	:	07/08/2015
Last Update Date	:	07/08/2015

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