Provider Demographics
NPI:1962992180
Name:SMYTH, SHANNON JENSEN (LPC, NCC, CCMHC)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:JENSEN
Last Name:SMYTH
Suffix:
Gender:M
Credentials:LPC, NCC, CCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2765 KISMET WAY
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-6208
Mailing Address - Country:US
Mailing Address - Phone:541-870-2751
Mailing Address - Fax:
Practice Address - Street 1:VA EUGENE DOWNTOWN CLINIC
Practice Address - Street 2:211 E. 7TH AVE
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-671-0448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5327101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty