1215413406 NPI number — SHELLEY ANN CRAWFORD JACKSON MS, LMHC, LPC

Table of content: MS. KRISTINE CHIN PT (NPI 1063553451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215413406 NPI number — SHELLEY ANN CRAWFORD JACKSON MS, LMHC, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAWFORD JACKSON
Provider First Name:
SHELLEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LMHC, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRAWFORD JACKSON
Provider Other First Name:
SHELLEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215413406
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 272
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDGEFIELD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98642-0272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-284-1463
Provider Business Mailing Address Fax Number:
360-326-7224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13505 NE 10TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98685-2711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-284-1463
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/11/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  C5800 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: LH61025530 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2104954 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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