MEDICARE: DR. JACK L SHORTRIDGE ED.D.

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	103TC1900X	Counseling Psychologist	KY-178	KY
2	106H00000X	Marriage & Family Therapist	1213	SC

General Provider Information

NPI Number	:	1811103468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK L SHORTRIDGE ED.D.

Provider Business Mailing Address
First Line	:	104 W SHEPARD LN
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29483-4242
Country	:	US
Telephone Number	:	843-821-0323
Fax Number	:

Provider Business Practice Location Address
First Line	:	5300 INTERNATIONAL BLVD
Second Line	:	WEBSTER UNIVERSITY
City	:	N CHARLESTON
State	:	SC
Zip	:	29418-6937
Country	:	US
Telephone Number	:	843-760-1324
Fax Number	:	843-760-1153

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	09/11/2025

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