Healthcare Provider Details

I. General information

NPI: 1962992180
Provider Name (Legal Business Name): SHANNON JENSEN SMYTH LPC, NCC, CCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 09/23/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA EUGENE DOWNTOWN CLINIC 211 E. 7TH AVE
EUGENE OR
97401
US

IV. Provider business mailing address

2765 KISMET WAY
EUGENE OR
97405-6208
US

V. Phone/Fax

Practice location:
  • Phone: 541-671-0448
  • Fax:
Mailing address:
  • Phone: 541-870-2751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC5327
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: