Provider Demographics
NPI:1285715847
Name:JENNINGS, SHANNON M (MD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:M
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 FARAON ST STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3512
Mailing Address - Country:US
Mailing Address - Phone:816-271-1066
Mailing Address - Fax:816-271-6786
Practice Address - Street 1:1501 S POTOMAC ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-5411
Practice Address - Country:US
Practice Address - Phone:636-484-0632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-147092084P0800X
MIEMC00012342084P0800X
MO20040016402084P0800X
IL0361165522084P0800X
TN643492084P0800X
MS293022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00405011OtherRR MEDICARE INDIVIDUAL #
MO208405506Medicaid
MOP00405011OtherRR MEDICARE INDIVIDUAL #
ILIL1392001Medicare PIN
MO919802493Medicare ID - Type Unspecified
MO208405506Medicaid
MOMA2048001Medicare PIN