| Doctor Name: | SHANE MICHELL JACKSON |
| NPI Number: | 1922173897 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LPC |
| License Number: | 4128 |
| Business Practice Address: | 115 W Tyler St Gilmer, TX - 756442239 |
| Business Phone Number: | 9037467643 |
| Business Fax Number: | 9038434336 |
| Mailing Address: | Po Box 1551, GILMER |
| State: | TX |
| Postal Code: | 756441551 |
| Phone Number: | 9037467643 |
| Fax Number: | 9038434336 |
| NPI Enumeration Date: | 11/22/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 4128 |
| Healthcare Provider Taxonomy: (Secondary) | X |
| State: | TX |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |