Provider Demographics
NPI:1194615336
Name:JACKSON, SHANNON L (MSW, LICSW, LADC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW, LICSW, LADC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:BARRAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1401 EAST 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-728-4404
Practice Address - Street 1:120 W 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2017
Practice Address - Country:US
Practice Address - Phone:218-728-4491
Practice Address - Fax:218-728-4404
Is Sole Proprietor?:No
Enumeration Date:2025-07-08
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN310071041C0700X
MN304733101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)