Provider Demographics
NPI:1194992081
Name:SHANNON, JESSIE YAO (PT)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:YAO
Last Name:SHANNON
Suffix:
Gender:F
Credentials:PT
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 1132
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO FALLS
Mailing Address - State:NH
Mailing Address - Zip Code:03896-1132
Mailing Address - Country:US
Mailing Address - Phone:603-569-5751
Mailing Address - Fax:
Practice Address - Street 1:576 JEFFERSON AVE
Practice Address - Street 2:MCDONALD ARMY HEALTH CENTER
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-5548
Practice Address - Country:US
Practice Address - Phone:757-314-7522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-10
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2724225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist