Provider Demographics
NPI:1215413406
Name:CRAWFORD JACKSON, SHELLEY ANN (MS, LMHC, LPC)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ANN
Last Name:CRAWFORD JACKSON
Suffix:
Gender:F
Credentials:MS, LMHC, LPC
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:CRAWFORD JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-0272
Mailing Address - Country:US
Mailing Address - Phone:360-284-1463
Mailing Address - Fax:360-326-7224
Practice Address - Street 1:13505 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2711
Practice Address - Country:US
Practice Address - Phone:503-284-1463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2025-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5800101YM0800X
WALH61025530101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2104954Medicaid