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NPI Code Detail

MEDICARE: SHAUNTAY JACKSON LMFT

MEDICARE: SHAUNTAY JACKSON LMFT
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
1106H00000XMarriage & Family Therapist002627-01NY

General Provider Information

NPI Number : 1902549405
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHAUNTAY JACKSON LMFT
Provider Business Mailing Address
First Line : 2541 OLINVILLE AVE APT 4B
Second Line :
City : BRONX
State : NY
Zip : 10467-7491
Country : US
Telephone Number : 347-318-7140
Fax Number :
Provider Business Practice Location Address
First Line : 2541 OLINVILLE AVE APT 4B
Second Line :
City : BRONX
State : NY
Zip : 10467-7491
Country : US
Telephone Number : 347-318-7140
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/14/2022
Last Update Date : 12/30/2025

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Directions to “ SHAUNTAY JACKSON LMFT” Practice Location

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