1053854349 NPI number — MS. JANCEY SHELLNUTT WILSON LPC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053854349 NPI number — MS. JANCEY SHELLNUTT WILSON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
JANCEY
Provider Middle Name:
SHELLNUTT
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILSON
Provider Other First Name:
JANCEY
Provider Other Middle Name:
SHELLNUTT
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1053854349
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 TYLER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THOMASTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30286-1454
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-647-7718
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 TYLER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THOMASTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30286-1454
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-647-7718
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/18/2016

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: 101YP2500X , with the licence number:  LPC008331 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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