Shane Michell Jackson, LPC

Primary specialty

Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X

License

4128 Issued in TX

Practice address

115 W Tyler St
Gilmer, TX 75644-2239

Phone

(903) 746-7643

Fax

(903) 843-4336

NPI assigned

Nov 22, 2006

Last updated

Sep 11, 2025By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Interoperability endpoints

• Direct secure messaging: shanejackson@tdh.allscriptsdirect.net

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Teladoc Health Medical Group, P.a.

  • Family Medicine Physician
  • Lewisville, TX
  • NPI 1245403567

  Mental Health

  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1164153600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1757548800000",
    "number": "1922173897",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1551",
            "city": "GILMER",
            "state": "TX",
            "postal_code": "756441551",
            "telephone_number": "903-746-7643",
            "fax_number": "903-843-4336"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "115 W TYLER ST",
            "city": "GILMER",
            "state": "TX",
            "postal_code": "756442239",
            "telephone_number": "903-746-7643",
            "fax_number": "903-843-4336"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "SHANE",
        "middle_name": "MICHELL",
        "credential": "LPC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-11-22",
        "last_updated": "2025-09-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "TX",
            "license": "4128",
            "primary": true
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "TX",
            "license": "16480",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LPC",
            "identifier": "16480",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LCDC",
            "identifier": "4128",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Omar Hudaib, RPH
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• Christina J Humber
• J M Taylor DDS Inc
• Mallory Sue Jackson, LPC-A, CSC
• Dalesia Rose James, ATC, LAT
• Tommie E Johnson Jr.
• Shawn Kenneth Johnston, OD
• Brittany Nicole Jordan, RN, BSN
• Joshua K. Furniss, DDS. PLLC

• Addiction (Substance Use Disorder) Counselor in Gilmer, TX
• Providers in Gilmer, TX by specialty
• Addiction (Substance Use Disorder) Counselor in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.