MEDICARE: JONATHAN ANTHONY SHECKLES M.H.P

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1871136739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN ANTHONY SHECKLES M.H.P

Provider Business Mailing Address
First Line	:	1400 E MCCORD ST
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3702
Country	:	US
Telephone Number	:	618-367-9016
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 E MCCORD ST
Second Line	:
City	:	CENTRALIA
State	:	IL
Zip	:	62801-3702
Country	:	US
Telephone Number	:	618-367-9016
Fax Number	:

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

Provider Enumeration Date	:	10/23/2019
Last Update Date	:	10/23/2019

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