Provider Demographics
NPI:1235749763
Name:JACKSON, SHELBY (LSW)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:2775 STATE ROUTE 39
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-9466
Mailing Address - Country:US
Mailing Address - Phone:419-747-3322
Mailing Address - Fax:
Practice Address - Street 1:2775 STATE ROUTE 39
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-9466
Practice Address - Country:US
Practice Address - Phone:419-747-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1700526104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker