Provider Demographics
NPI:1528050812
Name:SHANNON, JENNIFER LOUISE (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LOUISE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MSW, LICSW
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 2014
Mailing Address - Street 2:
Mailing Address - City:TRURO
Mailing Address - State:MA
Mailing Address - Zip Code:02666-2014
Mailing Address - Country:US
Mailing Address - Phone:508-487-1192
Mailing Address - Fax:508-487-5813
Practice Address - Street 1:30 CONWELL ST
Practice Address - Street 2:#1
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657-1548
Practice Address - Country:US
Practice Address - Phone:508-487-1192
Practice Address - Fax:508-487-5813
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA107036101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO4889Medicare ID - Type UnspecifiedLICSW