Provider Demographics
NPI:1326887399
Name:EVANS, SHANNON L
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:EVANS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 W VETERANS HWY
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-3410
Mailing Address - Country:US
Mailing Address - Phone:914-213-5093
Mailing Address - Fax:
Practice Address - Street 1:178 W VETERANS HWY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-3410
Practice Address - Country:US
Practice Address - Phone:914-213-5093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-21
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NJ1-24-72844103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst