Provider Demographics
NPI:1215155650
Name:SHANAHAN, JEROME DAVID PATRICK (MSW LMSW)
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:DAVID PATRICK
Last Name:SHANAHAN
Suffix:
Gender:M
Credentials:MSW LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 BAGLEY ST
Mailing Address - Street 2:1100
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1400
Mailing Address - Country:US
Mailing Address - Phone:313-961-7990
Mailing Address - Fax:313-961-6274
Practice Address - Street 1:220 BAGLEY ST
Practice Address - Street 2:1100
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-1400
Practice Address - Country:US
Practice Address - Phone:313-961-7990
Practice Address - Fax:313-961-6274
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010693491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical