Individual
SHANE MICHELL JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LPC
Contact information
Practice address
115 W TYLER ST, GILMER, TX 75644-2239
(903) 746-7643
(903) 843-4336
Mailing address
PO BOX 1551, GILMER, TX 75644-1551
(903) 746-7643
(903) 843-4336
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
4128
TX
101YM0800X
Mental Health Counselor
16480
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
16480
LPC
TX
01
—
4128
LCDC
TX
Enumeration date
11/22/2006
Last updated
09/11/2025
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