Provider Demographics
NPI:1194565457
Name:FATJO, SHANNON (LSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FATJO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1507
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:CO
Mailing Address - Zip Code:81639-1507
Mailing Address - Country:US
Mailing Address - Phone:970-761-8885
Mailing Address - Fax:
Practice Address - Street 1:302 HARVEST DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:CO
Practice Address - Zip Code:81639-5065
Practice Address - Country:US
Practice Address - Phone:970-761-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker