Healthcare Provider Details

I. General information

NPI: 1528050812
Provider Name (Legal Business Name): JENNIFER LOUISE SHANNON MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CONWELL ST #1
PROVINCETOWN MA
02657-1548
US

IV. Provider business mailing address

PO BOX 2014
TRURO MA
02666-2014
US

V. Phone/Fax

Practice location:
  • Phone: 508-487-1192
  • Fax: 508-487-5813
Mailing address:
  • Phone: 508-487-1192
  • Fax: 508-487-5813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number107036
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: