Provider Demographics
NPI:1194137356
Name:SHANNON, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:SHANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:THERRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 INDUSTRIAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062
Mailing Address - Country:US
Mailing Address - Phone:603-882-4500
Mailing Address - Fax:603-882-4545
Practice Address - Street 1:20 INDUSTRIAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03062
Practice Address - Country:US
Practice Address - Phone:603-882-4500
Practice Address - Fax:603-882-4545
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211102251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics