Provider Demographics
NPI:1871136739
Name:SHECKLES, JONATHAN ANTHONY (MHP)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ANTHONY
Last Name:SHECKLES
Suffix:
Gender:M
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E MCCORD ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3702
Mailing Address - Country:US
Mailing Address - Phone:618-367-9016
Mailing Address - Fax:
Practice Address - Street 1:1400 E MCCORD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3702
Practice Address - Country:US
Practice Address - Phone:618-367-9016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health