Provider Demographics
NPI:1144652991
Name:SHACKELFORD, JENNIFER (LPC, CAC II)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:LPC, CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 WOODGLEN LN
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-7513
Mailing Address - Country:US
Mailing Address - Phone:803-407-0819
Mailing Address - Fax:803-407-0819
Practice Address - Street 1:121 WOODGLEN LN
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-7513
Practice Address - Country:US
Practice Address - Phone:803-407-0819
Practice Address - Fax:803-407-0819
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-04
Last Update Date:2013-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1112215101YA0400X
SC2195101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)