Provider Demographics
NPI:1457003865
Name:SHORTER, JACKIE (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:
Last Name:SHORTER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1822 ELLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-8526
Mailing Address - Country:US
Mailing Address - Phone:910-309-0866
Mailing Address - Fax:
Practice Address - Street 1:2565 RAVENHILL DR STE 2C
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5414
Practice Address - Country:US
Practice Address - Phone:910-864-1799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021102013363LP0808X
NC5016089363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health